PN VATI Management 2020 completed

A nurse is caring for a client whose daughter requests to read her mother's medical record. Which of the following statements should the nurse make?

Answer: "I cannot allow you access to her medical record unless your mother gives her consent." Rationale: The nurse should not release private health information without the client's consent, as this is a violation of client confidentiality.

A nurse is reinforcing discharge teaching with a client following a vasectomy. Which of the following statements by the client indicates an understanding of the teaching?

Answer: "I should use ice packs to decrease swelling." Rationale: The nurse should instruct the client to apply ice to his scrotum for the first 12 to 24 hrs to reduce swelling and discomfort following a vasectomy.

A nurse is caring for a client who is scheduled for an arthroplasty. The client states, "I changed my mind. I don't want the surgery now." Which of the following responses should the nurse make?

Answer: "I will let your surgeon know that you have decided to cancel." Rationale: The nurse should respect the client's right to refuse treatment. It is the responsibility of the nurse to notify the surgeon that the client has changed their mind about the surgery.

A nurse is reinforcing preoperative teaching with a client who is scheduled for a below-the-knee amputation. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? ➖ "I will stay in bed with my stump elevated for the first 72 hours after surgery." ➖ " I will wear a stump sock over my stump to keep it clean." ➖ "I should cleanse my stump with hand sanitizer daily." ➖ "I should keep the initial pressure dressing on for 24 hours after surgery."

Answer: "I will wear a stump sock over my stump to keep it clean." Rationale: The nurse should identify that the client's statement indicates an understanding of the teaching. The client should wear a stump sock over the residual limb to facilitate cleanliness and comfort.

A nurse is reinforcing teaching with a client about advanced directives. Which of the following client statements should the nurse identify as an indication that the client understands the information? ➖ "The hospital will not admit me unless I have advance directives." ➖ "I'll discuss my wishes for my care with my family so they know what I want." ➖ " I'll make sure my doctor agrees with what I decide about my wishes for my care." ➖ "Once I sign and submit this document, I cannot change it."

Answer: "I'll discuss my wishes for my care with my family so they know what I want." Rationale: The client should discuss end-of-life care with their family and provider. This will allow the family to follow the client's advance directives if they can no longer speak for themselves.

A nurse is caring for a client who has just received a diagnosis of stage I lung cancer. The client tells the nurse that she is unsure about sharing the information with her brother. Which of the following responses should the nurse make?

Answer: "You can choose to keep your health care information private." Rationale: It is the nurse's responsibility to inform the client of their rights, including their right to confidentiality. A client's health care information should not be shared with others without the client's consent.

A nurse is caring for a client who has pancreatic cancer. The client tells the nurse that they do not want the chemotherapy the provider recommended. Which of the following responses should the nurse make? ➖ "You should discuss your treatment with your loved ones before making a decision." ➖ "You have the right to refuse chemotherapy, but you should understand the risks." ➖ "The side effects of chemotherapy are not as bad as they used to be and can be managed." ➖ "Your health will continue to decline if you don't receive chemotherapy."

Answer: "You have the right to refuse chemotherapy, but you should understand the risks." Rationale: The nurse should recognize the client's right to refuse treatment and notify the provider to discuss the risks of refusing treatment with the client.

The partner of a client who has been receiving dialysis tells the nurse that the client has stated a desire to end treatment. The client's partner is upset and asks the nurse for help. Which of the following responses should the nurse make?

Answer: "You seem upset. Tell me more about their reasons for making this decision." Rationale: This is a therapeutic response that demonstrates that the nurse recognizes the partner's feelings and respects the client's autonomy.

A charge nurse is reinforcing teaching with a newly licensed nurse about maintaining client's confidentiality. Which of the following statements should the charge nurse include? ➖ "You should place a client's vital signs on the white board in the client's room." ➖ " You may discuss information about a client's care with family members." ➖ "You may share an assigned password to access clients' records on the computer with another nurse." ➖ "You should encrypt client health information when sending e-mails."

Answer: "You should encrypt client health information when sending e-mails." Rationale: The nurse should encrypt client health information when sending e-mails to protect client confidentiality.

A nurse on a pediatric unit is assisting with the care for a group of clients. From which of the following clients should the nurse collect additional data first?

Answer: A child who had a tonsillectomy 12 hrs ago and is frequently clearing her throat. Rationale: A child who had a tonsillectomy 12 hrs ago and is clearing their throat or swallowing frequently is unstable; therefore, this client is the highest priority. Frequent clearing of the throat or swallowing is an indication of postoperative hemorrhage, which requires immediate care. The nurse should collect additional data from this client first before notifying the provider.

A nurse is providing care for an assigned group of clients. Which of the following clients should the nurse see first? ➖ A client who reports leg pain of 5 on a pain scale of 0 to 10. ➖ A client who reports diarrhea. ➖ A client who is scheduled to receive an antibiotic now ➖ A client who develops tachycardia

Answer: A client who develops tachycardia. Rationale: When using the airway, breathing, circulation approach to client care, the nurse's priority is checking on the client who develops tachycardia to ensure the client is not experiencing shortness of breath, angina, or shock.

A nurse is assisting with triage following a bus crash that caused multiple casualties. The nurse should identify which of the following clients as the priority? ➖ A client who has asymmetrical lung expansion and dyspnea ➖ A client who has an open fracture of the arm and swelling in the extremity ➖ A client who has a bleeding laceration of the head and reports a headache ➖ A client who has glass impaled in his hand and an avulsion skin injury to the thigh

Answer: A client who has asymmetrical lung expansion and dyspnea. Rationale: When using the survival approach to client care, the nurse should give priority to this client and recommend immediate transport. A client who has asymmetrical lung expansion and dyspnea has airway compromise, which requires immediate intervention for survival.

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

Answer: A client who is taking digoxin and has a digoxin level of 2.6 ng/mL. Rationale: A client who is taking digoxin and has a digoxin level of 2.6 ng/mL is unstable because of the risk for life-threatening dysrhythmias; therefore, the nurse should attend to this client first. The expected reference range for digoxin is 0.8 to 2.0 ng/mL. Digoxin toxicity begins at 2.4 ng/mL and can cause nausea, vomiting, diarrhea, and visual disturbances.

A nurse on a medical-surgical unit is expecting immediate admission of multiple clients due to a mass casualty incident. The nurse should recommend that the charge nurse discharge which of the following clients to accommodate new admission? ➖ A client who is receiving IV therapy for dehydration ➖ A client who is 12 hrs postoperative following knee arthroplasty ➖ A client who is receiving breathing treatments for status asthmaticus ➖ A client who is taking oral analgesics 1 day after a cholecystectomy

Answer: A client who is taking oral analgesics 1 day after a cholecystectomy. Rationale: A client who is taking oral analgesics 1 day after a cholecystectomy is stable. The nurse should recommend this client for discharge because the client is at the lowest risk for having an adverse event.

A nurse is caring for a client who is 2 days postoperative following a bowel resection. Which of the following information should the nurse communicate to the next nurse caring for this client? ➖ Family visits ➖ Preoperative laboratory values ➖ A new prescription for PO analgesics ➖ The procedure for incentive spirometer use

Answer: A new prescription for PO analgesics. Rationale: When giving change-of-shift report, the nurse should include any changes in the treatment plan, such as switching the client from parenteral to oral pain medication.

A nurse is reviewing incident reporting with a newly licensed nurse. For which of the following situations should the nurse plan to complete an incident report? ➖ A nurse changed a client's medication schedule due to medication incompatibility. ➖ A nurse left a client's IV tubing for a continuous infusion in place for 36 hrs. ➖ A visitor closed the restroom door on his hand. ➖ A family member yelled at a client and threatened never to see her again.

Answer: A visitor closed the restroom door on his hand. Rationale: The nurse should complete an incident report when anyone within the facility sustains an injury, including visitors.

A nurse is assisting with the care of a client who is postoperative following a total colectomy. Which of the following actions should the nurse take to support the client's autonomy?

Answer: Ask the client when he would like the staff to replace his bed linens. Rationale: Autonomy allows the client to participate in decision-making about his care. Giving the client options for the timing of nonessential procedures can increase his sense of control and autonomy.

A nurse in a long-term care facility is caring for a client who has dementia and is refusing to take an oral medication the provider prescribed. Which of the following actions should the nurse take?

Answer: Attempt to administer the medication later in the shift. Rationale: Clients who have dementia lack short-term memory. If the client previously took this medication without difficulty, a strategy that might work is to attempt to administer the medication to the client a short while later. The client might not remember the previous incident and take the oral medication.

A nurse is assisting with the transfer of a client who had a C7 spinal cord injury to a rehabilitation unit. Which of the following findings should the nurse identify as the priority to include in the transfer report? ➖ Autonomic dysreflexia ➖ Reddened coccyx ➖ Current vital signs ➖ Hypertension history

Answer: Autonomic dysreflexia Rationale: The greatest risk to the client is injury from autonomic dysreflexia due to the risk for hypertensive cerebrovascular accident and seizures. This is the priority finding for the nurse to include in the transfer report.

A nurse is caring for a client who has tested positive for vancomycin-resistant enterococci of the urine. Which of the following actions by the nurse demonstrates an understanding of infection control? ➖ Bagging soiled linens before exiting the client's room ➖ Placing the client in airborne isolation ➖ Standing within 1 m (3.3 feet) when caring for the client ➖ Applying a surgical mask to the client when transporting

Answer: Bagging soiled linens before exiting the client's room. Rationale: The nurse should bag the client's soiled linens before exiting the client's room to prevent accidental exposure and contamination to other clients or personnel.

A nurse is assisting in the plan of care for a client who has a sealed radium implant. Which of the following interventions should the nurse include in the plan? ➖ Limit visitors' exposure to the client to 1 hr per day. ➖ Check the client's linens for evidence of a dislodged implant. ➖ Remove the client's linens from the room at the end of each shift. ➖ Ensure that visitors keep a distance of at least 1 m (3.3 feet) from the client.

Answer: Check the client's linens for evidence of a dislodged implant. Rationale: The nurse should plan to check the client's linens for evidence of a dislodged implant to ensure the client's continuous treatment and reduce the risk of exposure to radiation.

A nurse is changing the tube feeding bag for a client who is receiving continuous feedings and sees that the feeding pump's electrical cord is frayed. Which of the following personnel should the nurse notify? ➖ Nurse supervisor ➖ Clinical engineer ➖ Pharmacist ➖ Housekeeper

Answer: Clinical engineer. Rationale: The nurse should remove the equipment from the client's room and notify the clinical engineer of the facility about the frayed cord. A frayed cord places the client and the facility at risk for an electrical injury or fire.

A charge nurse working in a long-term care facility is delegating tasks for the upcoming shift. Which of the following actions should the nurse take? ➖ Assign assistive personnel (AP) to clients, rather than to specific tasks. ➖ Communicate reporting guidelines for completion of tasks. ➖ Expect employees with the same job description to have the same competencies. ➖ Transfer accountability for delegated tasks to the person receiving the assignment.

Answer: Communicate reporting guidelines for completion of tasks. Rationale: Effective delegation requires communication, including the reports the staff should make to the nurse and when the reports should be made.

A nurse is reviewing the medication administration record of a client and notes that the client received an incorrect dose of medication. After ensuring that the client is safe, which of the following actions should the nurse take?

Answer: Complete an incident report about the medication error. Rationale: Once the nurse ensures the client is safe, the nurse who discovered the error should complete an incident report in a timely manner. An incident report allows the facility to analyze collected information to improve client safety and prevent future errors.

A nurse is assisting with the plan of care for a group of clients. Which of the following actions by the nurse demonstrates an effective use of time management skills? ➖ Beginning with the client's least important tasks first ➖ Starting a client procedure and gather supplies as needed ➖ Documenting interventions at the end of the shift ➖ Creating a list of tasks to be completed for the day

Answer: Creating a list of tasks to be completed for the day. Rationale: The nurse should create a list of tasks at the beginning of the shift to provide safe and effective care in a timely manner.

A nurse is delegating a task to an assistive personnel (AP). The AP states he is unsure about performing the task. Which of the following actions should the nurse take first?

Answer: Determine the AP's level of knowledge about the task. Rationale: The first actions the nurse should use when using the nursing process is to collect data from the AP to determine their level of knowledge of the task.

A nurse is contributing to the plan of care for a client who has heart failure. The client has been instructed to limit their sodium and fluid intake. Which of the following referrals should the nurse suggest? ➖ Social worker ➖ Occupational therapist ➖ Dietitian ➖ Physical therapist

Answer: Dietitian. Rationale: The nurse should suggest a referral for a dietitian who is specialized to consult the client about low-sodium food selections and fluid restrictions.

A nurse in a long-term care facility is assisting with developing a performance improvement (PI) plan. Which of the following actions should the nurse take first? ➖ Identify potential problems ➖ Determine outcomes ➖ Enforce methods to collect data ➖ Compare findings with standards

Answer: Identify potential problems. Rationale: Using the nursing process, first action the nurse should take in the performance improvement process is to allow all members of the health care team to identify potential problems.

A newly hired nurse is having conflict with another nurse who consistently demonstrates bullying behavior. Including excessive demands. Which of the following strategies should the newly hired nurse use to help de-escalate the situation? ➖ Inform the nurse that the behavior is unacceptable. ➖ Challenge the nurse about their demands. ➖ Compliment the nurse about the quality of care they provide. ➖ Request a transfer to a different nursing unit.

Answer: Inform the nurse that the behavior is unacceptable. Rationale: By informing the nurse that there is zero tolerance for bullying behavior, the newly licensed nurse is making it clear that there will be consequences if the bullying behavior continues. If it does, the newly hired nurse should report the behavior to the manager and send a written complaint to the facility's human resource department.

A nurse is preparing to administer a breathing treatment to a client who has COPD. The client states, "I don't want to have this done. I don't like it blowing in my face." Which of the following responses should the nurse give? ➖ "I will come back later when you are not upset." ➖ "You need to do this treatment four times every day." ➖ "You won't feel better if you don't do your treatment." ➖ "Let's discuss the importance of your breathing treatment."

Answer: Let's discuss the importance of your breathing treatment." Rationale: The nurse should verify that the client understands the reasons for the breathing treatment along with the benefits and risks. However, the nurse should respect the client's right to refuse.

A nurse is assisting with completing a transfer report for a client who sustained spinal cord injuries and is moving to a long-term care facility for rehabilitative care. Which of the following information should the nurse include?

Answer: List of continuing treatments. Rationale: The nurse should provide the receiving nurse and facility with pertinent client information to facilitate continuity of care. A list of the client's continuing treatments should be provided in the transfer report in order to maintain care and address the client's current needs.

A nurse is assisting in assigning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? ➖ Check a client's nasogastric feeding tube placement. ➖ Assist with feeding a client who is new to the unit and requires swallowing precautions. ➖ Reinforce instructions for using an incentive spirometer with a client. ➖ Measure the vital signs of a client who is 24 hr postoperative following a cholecystectomy.

Answer: Measure the vital signs of a client who is 24 hr postoperative following a cholecystectomy. Rationale: Measuring vital signs is within the AP's range of function. The nurse should collect data from the client to ensure the client is stable prior to assigning this task to the AP. After collection, the AP should report the vital signs to the nurse.

A nurse is completing an incident report for a client found on the bathroom floor next to his wheelchair. Which of the following information should the nurse include in the incident report? ➖ Conclusion about the cause of the fall ➖ Names of any witnesses to the occurrence ➖ Summary of the client's words about the occurrence ➖ Recommendation for preventive measures

Answer: Names of any witnesses to the occurrence. Rationale: The nurses should include names of witnesses to the occurrence in the incident report. The nurse should also include the client's name, initials, identification number, and the date and time of the occurrence.

A nurse smells alcohol on the breath of another nurse while discussing a client's condition. Which of the following actions should the nurse take?

Answer: Notify the charge nurse of the situation. Rationale: The nurse has an ethical responsibility to protect clients and report suspected substance use. The nurse should notify the charge nurse of the incident, which would allow the charge nurse to investigate further and take actions to maintain the safety of clients.

A nurse is caring for a client who is considering surgery. The client asks the surgeon about alternative holistic therapies, but the surgeon does not want to discuss those options with the client. Which of the following actions should the nurse take? ➖ Discuss the benefits of the surgical procedure with the client. ➖ Notify the nurse manager about the situation. ➖ Explain the risks and benefits of using alternative medicine to the client. ➖ Reassure the client that the surgeon wants to provide the best possible care.

Answer: Notify the nurse manager about the situation. Rationale: It is the surgeon's responsibility to respond to the client's questions and to provide information about alternative therapies. The nurse should discuss this issue with the nurse manager.

A nurse working on a medical-surgical unit has concerns about ongoing staffing shortages that compromise client safety and delivery of care. Which of the following actions should the nurse take?

Answer: Notify the nursing supervisor. Rationale: It is the responsibility of the nurse to report situations that create the potential for unsafe practice, such as staffing shortage, to the nursing supervisor.

A nurse is preparing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? ➖ Instruct a client about postoperative breathing. ➖ Change a dressing on an invasive line for a client. ➖ Insert an indwelling urinary catheter for an incontinent client. ➖ Obtain a scheduled blood glucose reading for a client who is stable.

Answer: Obtain a scheduled blood glucose reading for a client who is stable. Rationale: The nurse should assign the AP to obtain a scheduled blood glucose reading on a stable client. This task is within the range of function for an AP. However, if a client's condition is unstable, a licensed nurse should obtain the client's blood glucose reading.

A nurse is assisting with the admission of a client who is planning to have surgery. The client has severe hearing loss and is unable to hear the preoperative instructions. Which of the following actions should the nurse take? ➖ Speak directly into the client's ear. ➖ Offer the client a sign-language interpreter. ➖ Ask the client why they didn't bring a family member with them. ➖ Speak loudly when addressing the client.

Answer: Offer the client a sign-language interpreter. Rationale: The nurse should attempt to verify that the client uses and understands sign language. Having an interpreter who uses sign language is the best way to make sure the client understands the information and can ask and receive answers to their questions. Finding a way to have effective two-way communication with the client demonstrates advocacy.

A nurse is contributing to the plan of care for an adolescent who is in sickle cell crisis. Which of the following instructions should the nurse suggest for the plan? ➖ Restrict oral fluids. ➖ Apply cold compresses. ➖ Administer rifampin PO daily. ➖ Perform passive range-of-motion exercises.

Answer: Perform passive range-of-motion exercises. Rationale: The nurse should encourage the client to perform passive range-of-motion exercises to promote circulation. Clients who are in sickle cell crisis should not engage in vigorous activity because this can increase the occurrence of sickling.

A nurse is reinforcing discharge teaching with a client who is recovering from a stroke and has hemiparesis along with dysphagia. Which of the following instructions should the nurse include in the teaching? ➖ Include crackers with peanut butter as a snack. ➖ Rest for 15 min prior to mealtimes. ➖ Place food in the stronger side of mouth. ➖ Extend the neck when swallowing foods.

Answer: Place food in the stronger side of mouth. Rationale: The nurse should instruct the client to place food in the unaffected side of their mouth. This aids in the chewing and swallowing of food and reduces the risk for aspiration.

A nurse in a long-term care facility is preparing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? ➖ Perform a sterile dressing change on a client's central line. ➖ Provide postmortem care for a client. ➖ Educate a client on the use of antiembolic stockings. ➖ Monitor a client's pain level.

Answer: Provide postmortem care for a client. Rationale: The nurse should delegate postmortem care to the AP. This task is within the range of function of an AP.

A nurse enters a client's room and finds that smoke is coming from an electrical outlet. After assisting the client out of the room, which of the following actions should the nurse take next? ➖ Obtain a fire extinguisher. ➖ Turn off electrical equipment. ➖ Pull the nearest fire alarm. ➖ Close the doors and windows to the client's room.

Answer: Pull the nearest fire alarm. Rationale: The greatest risk to this client is injury from burns and smoke inhalation. Therefore, when using the RACE method for fire response, the next action the nurse should take is to sound the alarm. Then, the nurse should attempt to contain the fire by sealing off the doors and windows and turning off all electrical equipment. Lastly, the nurse should attempt to extinguish the fire.

A nurse is assisting with an interdisciplinary team to use clinical data to improve outcomes. Which of the following competencies of Quality and Safety Education for Nurses (QSEN) is the nurse demonstrating? ➖ Patient-centered care ➖ Evidence-based practice ➖ Quality improvement ➖ Informatics

Answer: Quality improvement. Rationale: This QSEN competency involves the use of data to track outcomes and improvement processes to devise a plan to improve the safety of health care services and improve client's outcomes.

A newly licensed nurse is delegating tasks to an assistive personnel (AP). The AP refuses to perform the delegated tasks. Which of the following actions should the nurse take? ➖ Ask another staff member about the AP's performance. ➖ Request that another nurse delegates tasks to the AP. ➖ Inform the AP of the consequences of continued resistance to delegation. ➖ Report the AP's behavior to the nurse manager.

Answer: Report the AP's behavior to the nurse manager. Rationale: The nurse should address the conflict with the AP and report the actions of the AP to the nurse manager. The nurse manager is responsible for the resolution of workplace conflicts.

A nurse enters a client's room and overhears the assistive personnel (AP) talking with the client about the condition of the client in the room next door. Which of the following actions should the nurse take? ➖ Report the incident to the charge nurse. ➖ Clarify with the client what information the AP discussed. ➖ Confront the AP in front of the client about violating client confidentiality. ➖ Close the door to the client's room so the client next door does not hear the discussion.

Answer: Report the incident to the charge nurse. Rationale: According to the Health Insurance Portability and Accountability Act (HIPAA), the nurse has a legal obligation to protect the disclosure of client's personal information. The AP is breaching the other client's confidential information. The nurse should report the incident to the lowest person in the facility hierarchy that is responsible for addressing the situation. Therefore, the nurse should report this information to the charge nurse to ensure client safety.

A newly licensed nurse has just completed orientation on a medical-surgical unit. The nursing supervisor asks the nurse to float to the labor and delivery unit. Which of the following actions should the newly licensed nurse take?

Answer: Request to float to an adult medical-surgical unit instead. Rationale: The nurse should recognize that this assignment is unsafe due to a lack of experience and orientation to the labor and delivery unit. The nurse should confer with the supervisor for an alternate assignment.

A nurse is assisting with admitting a client who has cystic fibrosis. For which of the following health care team members should the nurse anticipate a referral? ➖ Speech-language pathologist ➖ Respiratory therapist ➖ Physical therapist ➖ Social worker

Answer: Respiratory therapist. Rationale: Respiratory therapists can assist clients who have breathing problems and disorders, such as cystic fibrosis. They also conduct pulmonary function tests and help clients manage oxygen therapy equipment.

A nurse is contributing to the plan of care for a client who has dementia and follows a kosher diet. Which of the following food choices should the nurse select for the client?

Answer: Salmon. Rationale: Most clients who follow a kosher diet consume only fish with fins and scales; therefore, salmon is a good food choice for this client.

A nurse is contributing to the plan of care for four clients on a medical-surgical unit. The nurse should plan to use sterile gloves while performing which of the following procedures? ➖ Suctioning a client's tracheostomy ➖ Removing a client's peripherally inserted IV catheter ➖ Collecting a stool specimen for a culture ➖ Administering a feeding via a percutaneous endoscopic gastrostomy (PEG) tube.

Answer: Suctioning a client's tracheostomy. Rationale: Suctioning a client's tracheostomy is an invasive procedure that requires strict aseptic technique. The nurse should wear sterile gloves to reduce the risk for infection.

A nurse is caring for a client who has a facial injury. The client tells the nurse that the injury was a result of partner violence. After treating the client's physical injury. Which of the following actions should the nurse take next? ➖ Provide coping strategies. ➖ Refer the client for counseling services. ➖ Assist the client to develop a safety plan. ➖ Take photos of the client's injuries.

Answer: Take photos of the client's injuries. Rationale: The first action the nurse should take using the nursing process is to collect data from the client by documenting and taking photos of the client's injuries. Accurate documentation of the client's injuries in the medical record can provide valuable evidence in the event future legal action is taken against the perpetrator.

A nurse in a long-term care facility is assisting with the preparation of an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings should the nurse identify as the priority to report at the conference? ➖ The client reports worsening episodes of insomnia. ➖ The client is displaying a more pronounced propulsive gait. ➖ The frequency of the client's mood swings is increasing. ➖ The client has asked for medication to treat seborrhea.

Answer: The client is displaying a more pronounced propulsive gait. Rationale: The greatest risk to this client is injury from falling due to a more pronounced propulsive gait. Therefore, this is the priority finding the nurse should report.

A home health nurse is visiting a client who has a new diagnosis of Parkinson's disease. Which of the following findings should the nurse plan to address first?

Answer: The client's medications are missing. Rationale: The greatest risk to this client is injury from interruption in the client's medication regimen. Abrupt withdrawal from some medications can cause severe adverse effects. Therefore, the priority finding for the nurse to address is the client's missing medications.

A home health nurse is visiting a client who is receiving continuous humidified oxygen. To ensure safe care, the nurse should intervene for which of the following findings? ➖ The client's portable oxygen tank does not have a flow meter. ➖ The client is using a cotton blanket to keep his legs warm. ➖ The client uses tap water to fill the humidifier for his oxygen. ➖ The client's oxygen concentrator is 4.6 m (15 feet) from the fireplace.

Answer: The client's portable oxygen tank does not have a flow meter. Rationale: Without a flow meter, the nurse cannot be sure that the client is receiving the amount of oxygen the provider prescribed. The nurse should assist the client with communicating with the medical equipment supplier to obtain functioning equipment.

A nurse is contributing to the plan of care for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse suggest for this client? ➖ The client's room should have negative-pressure airflow. ➖ The nurse should don a surgical mask before entering the client's room. ➖ The nurse should wear a gown when providing care to the client. ➖ The staff should clean their hands with alcohol-based hand rub unless visible contamination is present.

Answer: The nurse should wear a gown when providing care to the client. Rationale: The nurse should plan to implement contact precautions for a client who has a C. difficile infection, which includes wearing a gown when providing care to the client, to reduce the risk for transmission of the infection.

A charge nurse is encouraging two nurses who have a conflict about the vacation schedule to use conflict management strategies to resolve their issue. The nurses agree to select vacation days that do not overlap. The nurses are demonstrating which of the following approaches to conflict management? ➖ Win-lose ➖ Win-yield ➖ Lose-lose ➖ Win-win

Answer: Win-Win. Rationale: Without the power struggle over who should have which vacation days, the nurses challenge themselves to resolve conflict by finding alternatives that work for both parties. Using this strategy, neither nurse should exhibit anger or passive-aggressive behavior; Instead there is a sincere effort to resolve the conflict equitably.

A nurse is assisting with planning an in-service regarding client advocacy. The nurse should recommend which of the following topics be included in the in-service? Select all that apply.

Correct Answers: Nurse advocates support clients with making health care decisions. A nurse advocate protects the rights of clients. The nurse should support the client with making health care decisions, which promotes autonomy. Nurse advocates promote clients' access to health care. A nurse advocate protects the rights of clients. The nurse should ensure that all clients have access to health care. Nurse advocates mediate conflicts between clients and other staff regarding treatment. A nurse advocate protects the rights of clients. The nurse should mediate conflicts between clients and other staff regarding treatment to ensure that clients receive care to meet their needs.

A nurse is assisting with the admission of a client who has a Clostridium difficile infection. Which of the following precautions should the nurse take? Select all that apply. ➖ Clean the client's room using a bleach solution. ➖ Wash hands using an alcohol-based foam. ➖ Wear a mask when entering the client's room. ➖ Wear clean gloves while performing client care. ➖ Place the client in a private room.

Correct Answers: Clean the client's room using a bleach solution. The nurse should clean the client's room using a bleach solution to kill the bacterial spores. Wear clean gloves while performing client care. The nurse should wear clean gloves while caring for a client who has a C. difficile infection. Place the client in a private room. The nurse should place the client in a private room to isolate the infection from other clients. If a private room is not available, the nurse should place this client in a room with another client who is infected with the same bacteria.

A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse recommend for delegation to an assistive personnel (AP). Select all that apply. ➖ Feeding a client who has had casts on both arms for 48 hrs. ➖ Obtaining vital signs of a client who is stable and arrived from the PACU 2 hr. ago. ➖ Performing a sterile dressing change for a client who has a leg wound ➖ Transporting a client's clean-voided urine specimen to the laboratory ➖ Reinforcing teaching with the client about the use of a quad cane

Correct Answers: Feeding a client who has had casts on both arms for 48 hrs. The nurse can delegate feeding a client who has had casts on both arms for 48 hr because this client is stable and the task is routine. Obtaining the vital signs of a client who is stable and arrived from the PACU 2 hr. ago. The nurse can delegate measuring the vital signs of clients who are postoperative to an AP if the client is stable. Transporting a client's clean-voided urine specimen to the laboratory. The nurse can delegate transporting specimens to the laboratory because it is a routine task that does not require technical knowledge.

A nurse is assisting with the informed consent process with a client who is about to undergo surgery. Which of the following actions should the nurse take? Select all that apply. ➖ Explain the procedure. ➖ Discuss the expected outcomes of the procedure. ➖ Inform the client of their right to refuse the procedure. ➖ Verify that the client understands the procedure. ➖ Identify the risks of the procedure.

Correct Answers: Inform the client of their right to refuse the procedure. The nurse should inform the client that they have the right to refuse the procedure at any time, even after they have signed the consent form. Verify that the client understands the procedure. The nurse should verify that the client understands the procedure and that the surgeon has explained it to them.

A nurse is discussing advantages of using the nursing clinical information system (NCIS) with a newly licensed nurse. Which of the following advantages should the nurse include? Select all that apply. ➖ Eliminates potential legal risk ➖ Gives an overview of the cost of treatment ➖ Reduces errors of omission ➖ Enhances ability to track medical records ➖ Provides immediate access to members of the interprofessional team

Correct Answers: Reduces errors of omission. An advantage of computerized documentation is a reduction in errors of omission. Data, such as prior shift assessment information, can be copied, allowing a nurse to quickly document updates without potentially forgetting to document other information. Enhances ability to track medical records. Computerized documentation enhances the ability to track the client's medical records. Records are easily organized and stored and can be retrieved quickly when a client is readmitted from a previous encounter. Provides immediate access to members of the interprofessional team. Computerized documentation provides immediate access to members of the interprofessional team. Important information, such as allergies and current medications, can be retrieved by health care team members in other departments prior to providing care to a client.