Team Lead PrepU (CC4)

After several years of providing bedside care in an inpatient setting, a nurse has taken a position with the state board of nursing. In this role, the nurse may contribute to which activity of a state board of nursing? a. Allocating financial resources within clinics and hospitals in the state b. Promoting the visibility of the nursing profession within the state c. Issuing and transferring nursing licenses within the state d. Providing consultation on ethically challenging clinical situations

c. Issuing and transferring nursing licenses within the state

The nurse is delegating a task to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? a. "Notify me right away if the client's systolic blood pressure is 170 or greater." b. "I need to know if the client's blood pressure changes from the normal baseline." c. "Let me know if the client's blood pressure becomes elevated." d. "If the client's blood pressure falls outside normal limits, come get me."

a. "Notify me right away if the client's systolic blood pressure is 170 or greater."

Which nursing care task is acceptable for a registered nurse to delegate to an unlicensed assistive personnel (UAP)? a. Assisting a client with ambulation b. Development of a client teaching plan c. Initial and ongoing assessments d. Evaluation of nursing care delivered to a client

a. Assisting a client with ambulation

The nurse caring for a client learns that a care delivery error was made on the previous shift of which the client is not aware. After assessing the client and determining there are no evident adverse effects, what action should the nurse take next? a. Disclose the error to the client, and discuss how this could affect the client's care. b. Inform the client of the current assessment findings, but do not mention the error. c. Discuss the error with the charge nurse to determine if it should be mentioned to the client. d. Notify the client's family about the error, and reassure them that there was no harm to the client.

a. Disclose the error to the client, and discuss how this could affect the client's care.

While the nurse is transferring a confused client from the chair to the bed, the client bites the nurse on the arm. Out of frustration, the nurse slaps the client across the face, leaving a large bruise. The nurse's behavior is reported to the nurse manager. What is the most appropriate action for the nurse manager to take? a. Support the claim of battery brought by the client's family. b. Reprimand the nurse for the outburst of abusive behavior. c. Suspend the nurse from work for negligent behavior. d. Send the nurse to an anger management workshop.

a. Support the claim of battery brought by the client's family.

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which client condition must the nurse immediately bring to the surgeon's attention? a. The client was given morphine 6 mg IM 20 minutes ago. b. The client is diagnosed with malignant hypertension. c. The client states a pain rating of 8 out of 10. d. The client has a temperature of 100.4 degrees F (38 degrees C).

a. The client was given morphine 6 mg IM 20 minutes ago.

Which situation is an indication of the benefit of self-awareness in professional nursing practice by a nurse? Select all that apply. a. Appears more tolerant to different practices b. Understands the meaning of cultural diversity c. No longer is affected by biases and assumptions d. Examines own biases and is open to new ideas e. Questions all situations for underlying meanings

b. Understands the meaning of cultural diversity d. Examines own biases and is open to new ideas

The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in airborne precautions? Select all that apply. a. A client diagnosed with respiratory syncytial virus b. A client with a positive wound culture for Methicillin resistant Staphylococcus aureus (MRSA) c. A client diagnosed with chicken pox d. A client diagnosed with tuberculosis e. A client with a new onset of diarrhea

c. A client diagnosed with chicken pox d. A client diagnosed with tuberculosis

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication? a. SMS b. e-mail c. checklists d. notepad

c. Checklists

A nurse who is a case manager is responsible for assigning client care to unlicensed assistive personnel (UAPs). The nurse is planning the care for a new pediatric client who requires several treatments. Which UAP will the nurse assign to care for the new client? a. The UAP with the best time management and organizational skills b. The UAP who has had supervised practice with all of the required treatments c. The UAP who is the friendliest with the children on the unit d. The UAP who has independently provided the same treatments to clients in the past

d. The UAP who has independently provided the same treatments to clients in the past

A client who is a Jehovah's Witness consented to surgery only and not to receiving any blood products, including autotransfusion. During surgery, the client lost blood, the blood pressure dropped, and two units of blood were administered. Following surgery, during handover the nurse was informed that the blood had been administered. In which order, from first to last should the nurse complete these tasks? 1. Notify the unit manager. 2. Complete an incident report. 3. Inform the next oncoming nurse during hand off of care report. 4. Initiate an ethics consultation.

4. Initiate an ethics consultation. 1. Notify the unit manager. 2. Complete an incident report. 3. Inform the next oncoming nurse during hand off of care report.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? a. Correct the problem and submit a written report. b. Speak to the coworker upon return to the unit. c. Inform the nurse supervisor right away. d. Ask for a meeting with the coworker and a manager.

b. Speak to the coworker upon return to the unit.

A nurse is considering the delegation of administering topical medications to an unlicensed assistive personnel (UAP). What is the first question the nurse must ask oneself before doing so? a. Do the nurse practice act and agency policy allow this delegation? b. Has the UAP been trained to perform the task? c. Have I evaluated the client's response to this task? d. Is appropriate supervision available for the UAP?

a. Do the nurse practice act and agency policy allow this delegation?

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of a. Nursing informatics. b. Telemedicine. c. Computerized documentation. d. Electronic medical records.

a. Nursing informatics

The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in contact precautions? Select all that apply. a. A client with a new onset of diarrhea b. A client with a positive wound culture for methicillin-resistant Staphylococcus aureus (MRSA) c. A client diagnosed with respiratory syncytial virus (RSV) d. A client diagnosed with chicken pox e. A client diagnosed with tuberculosis

a. A client with a new onset of diarrhea b. A client with a positive wound culture for methicillin-resistant Staphylococcus aureus (MRSA) c. A client diagnosed with respiratory syncytial virus (RSV)

A client has a complex medical history involving consequences of type 1 diabetes. As a result of diabetic nephropathy, the client now is involved in the local hospital's dialysis program and has been referred to an ophthalmologist by the primary care physician following vision problems. In addition, the client receives home care nursing for treatment of a foot ulcer that is slow to heal. This client's situation characterizes which phenomena? a. Fragmentation of care b. Primary care c. Managed care d. Case management

a. Fragmentation of care

A nurse uses the Nurse Practice Act to guide professional standards. Which actions are within the scope of the registered nurse? Select all that apply. a. Initiate a plan of care for a client with vertigo. b. Administer an intravenous medication to decrease blood pressure. c. Administer conscious sedation. d. Delegate basic hygiene to an unlicensed assistive personnel. e. Provide insulin injection teaching to a new diabetic client.

a. Initiate a plan of care for a client with vertigo. b. Administer an intravenous medication to decrease blood pressure. d. Delegate basic hygiene to an unlicensed assistive personnel. e. Provide insulin injection teaching to a new diabetic client.

The nurse completes an incident report after discovering and assessing a client sitting on the floor beside the bed. Which actions should the nurse take after completing the incident report? Select all that apply. a. Notify the nursing supervisor. b. Document the completion of the report in the medical record. c. Send a copy of the report to the risk management department. d. Document the client's condition. e. Notify the physician.

a. Notify the nursing supervisor. c. Send a copy of the report to the risk management department. d. Document the client's condition. e. Notify the physician

A nurse asks a nursing colleague to witness a narcotic waste. The nurse says, "On night shift we just sign for it and no one really watches the waste." What is the best response by the nurse witnessing the narcotic waste? Select all that apply. a. "I would be careful if you are not following the hospital policy." b. "I cannot just sign and not witness the waste." c. "I will need to witness the waste before I sign for it." d. "I think your team works well together on this unit." e. "I will do it the same way you are used to doing the waste."

b. "I cannot just sign and not witness the waste." c. "I will need to witness the waste before I sign for it."

The nurse is preparing to begin discharge planning with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process? a. The nursing diagnoses relevant to the client's condition b. The client's potential for recurrence c. The client's identified needs and goals d. The nurse's knowledge base and experience level

c. The client's identified needs and goals

The nurse is having an exceptionally busy shift on an obstetrical unit. Which task is the nurse justified in delegating to an unlicensed care provider? a. Giving an anti-inflammatory medication to a client who is eight hours postdelivery b. Helping a first-time mother achieve a good latch when breastfeeding the infant c. Assessing the size and quantity of clots that are in a client's bedpan and informing the nurse d. Emptying a client's Foley catheter bag and reporting the volume to the nurse

d. Emptying a client's Foley catheter bag and reporting the volume to the nurse

A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? a. Interview the nurse's other clients to see if the nurse attempted to sell supplements to them. b. Tell the client that the client should not purchase anything from the nurse. c. Report the nurse to the nurse manager and the nursing regulatory body. d. Inform the nurse that selling supplements to clients is a conflict of interest.

d. Inform the nurse that selling supplements to clients is a conflict of interest.

An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that the client not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which would be the best response by the nurse? a. "It is your responsibility, as I have already stated to you." b. "You are making the situation more difficult than it really is." c. "I recommend family members arrange to stay with the client." d. "The hospital cannot be responsible for the client's safety if you won't let us use restraints."

c. "I recommend family members arrange to stay with the client."

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours? Client 1 : 1300 - After lunch toileting Client 2 : 1300 - Dressing change to left heel wound Client 3 : 1300 - Intravenous piggyback (100cc) every 6h Client 4 : 1300 - Soonest time for requested post-op pain medication a. Client 2, Client 1, Client 3, Client 4 b. Client 3, Client 1, Client 2, Client 4 c. Client 4, Client 3, Client 2, Client 1 d. Client 4, Client 1, Client 3, Client 2

c. Client 4, Client 3, Client 2, Client 1

A nurse who provides care on a post-surgical unit is performing discharge teaching as a component of the nurse's effort to ensure continuity of care. Which is the primary goal of continuity of care? a. Minimizing nurses' legal liability during client transitions between healthcare institutions b. Controlling costs and maximizing client outcomes after discharge from the hospital c. Ensuring a smooth and safe transition between different healthcare settings d. Increasing clients' knowledge base and health maintenance behaviors

c. Ensuring a smooth and safe transition between different healthcare settings

The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is a. stablishing goals with client. b. Collecting and organizing data about the client. c. Providing home healthcare referrals. d. Teaching the client self-care activities to be conducted in the home setting.

b. Collecting and organizing data about the client.

The nurse is working with a client with end stage cancer. The nurse obtains a healthcare practitioner order to access a central line for chemotherapy. The nurse has never accessed this type of central line. Which practices can the nurse use to ensure client safety? Select all that apply. a. Inform the healthcare provider that this is a new procedure. b. Refuse to access the central line. c. Work with another nurse to access the central line. d. Start a peripheral line because the central line access is not a familiar procedure. e. Read the institutional policy for central line access.

b. Refuse to access the central line. c. Work with another nurse to access the central line. e. Read the institutional policy for central line access.

The nurse is assigned to care for five clients. Which could be assigned by the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. a. A client returning from the operating room post-colectomy for ulcerative colitis b. A client scheduled for cataract surgery with BP 134/78 mm Hg, pulse 70 bpm c. A client with a diagnosis of cholelithiasis reporting pain of 8 out of 10 d. A newly admitted client with wheezing from an allergic reaction e. A client post-operative appendectomy with BP 110/80 mm Hg, pulse 84 bpm

b. A client scheduled for cataract surgery with BP 134/78 mm Hg, pulse 70 bpm e. A client post-operative appendectomy with BP 110/80 mm Hg, pulse 84 bpm

A nurse returns to a computer terminal and realizes he or she did not log off the last time he or she used it. What action should be the nurse's priority? a. Restart the computer to reset it and log back in with his or her log-in credentials. b. Change the password previously used and notify the computer department of the breach. c. Check that all recent documentation was saved as entered and not altered. d. Notify the charge nurse and complete an occurrence report related to the incident.

b. Change the password previously used and notify the computer department of the breach.

There are a limited number of capnography monitors available on the unit. The nurse prioritizes which clients as requiring ongoing capnography? Select all that apply. a. Client with severe hemolytic anemia and low blood pressure b. Client with increased intracranial pressure due to trauma c. Client with acute exacerbation of chronic obstructive pulmonary disease d. Client being treated for an uncontrolled seizure disorder e. Client scheduled for a procedure using moderate sedation

b. Client with increased intracranial pressure due to trauma c. Client with acute exacerbation of chronic obstructive pulmonary disease d. Client being treated for an uncontrolled seizure disorder e. Client scheduled for a procedure using moderate sedation

A client expresses a desire to walk to the lobby for discharge to home. The unlicensed assistive personnel (UAP) tells the client that all clients being discharged need to be transferred to the lobby by wheelchair. How will the nurse best respond to protect the client's right of care? Select all that apply. a. "At this hospital clients must be discharged by wheelchair to the lobby." b. "The client has the right to walk to the lobby for discharge." c. "An employee will accompany you to the lobby if you choose to walk." d. "It is the hospital policy for the client to use a wheelchair to the lobby when being discharged." e. "Clients are at risk for falls if they do not use the wheelchair when being discharged."

b. "The client has the right to walk to the lobby for discharge." c. "An employee will accompany you to the lobby if you choose to walk."

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take? Select all that apply. a. Place the client in the semi-Fowler's position. b. Call the health care provider (HCP) and report the situation using SBAR format. c. Stay with and reassure the client. d. Confirm the client's vital signs and complete a quick assessment. e. Make a quick check on other assigned clients before spending the time required to take care of this client. f. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team.

a. Place the client in the semi-Fowler's position. b. Call the health care provider (HCP) and report the situation using SBAR format. c. Stay with and reassure the client. d. Confirm the client's vital signs and complete a quick assessment. f. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team.

A RN is delegating client care responsibilities to a licensed practical/vocational nurse (LPN/VN). Which nursing responsibilities would be appropriate to delegate to the LPN/VN? Select all that apply. a. Reinforcing the teaching of proper diabetic diet. b. Assessing the client's swallowing ability before feeding. c. Changing the client's decubitus foot ulcer dressing. d. Obtain a bedside glucose specimen test at 1100. e. Administering the client's Lasix 80mg IVP stat.

a. Reinforcing the teaching of proper diabetic diet. c. Changing the client's decubitus foot ulcer dressing. d. Obtain a bedside glucose specimen test at 1100.

When maintaining medical records for a client, the nurse knows that a medical record also serves as legally admissible evidence. What should the nurse do to ensure legally defensible charting? a. Record all facts and subjective interpretations. b. Ensure that the client's name appears on all pages. c. Leave spaces between entries and signature. d. Use abbreviations wherever possible.

b. Ensure that the client's name appears on all pages.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? a. Tell the nurse that as an RN, the nurse should be competent to work in any area. b. Find another nurse to cover the unit and send the nurse back to the surgery unit. c. Tell the nurse to buddy up with someone else and do the best that the nurse can do. d. Give the nurse the lightest workload on the unit.

b. Find another nurse to cover the unit and send the nurse back to the surgery unit.