Transitions - Management

A nurse observes an assistive personnel (AP) taking a picture of a client who has not given consent. The nurse should identify the AP has committed which of the following torts? 1 - Invasion of privacy 2 - Negligence 3 - Defamation of character 4 - Battery

1 - Invasion of privacy Rational 1- Invasion of privacy is a violation of the client's right to privacy, such as using the client's name for profit or taking pictures of the client without consent. 2 - Negligence is a failure to provide the expected standard of care. 3 - Defamation of character is publishing false information about a client that results in harm to his reputation. 4 - Battery is offensive physical contact with the client without his consent, whether or not harm is caused.

A nurse is contributing to the plan of care for a client who states he is a devout Hindu. To adhere to the client's religious dietary practices, which of the following foods options should the nurse offer to the client? 1 - Tomato soup 2 - Yogurt 3 - Hamburger 4 - Pork chop

2 - Yogurt Rational 1 - The nurse should not offer tomato soup to the client because many devout Hindus do not consume blood-colored food. 2 - The nurse should offer yogurt as a food option for the client who is a devout Hindu because dairy products are believed to enhance spiritual purity. 3 - The nurse should not offer a hamburger to the client because many devout Hindus do not consume beef products. 4 - The nurse should not offer a pork chop to the client because many devout Hindus do not consume pork products.

Food safety - disaster kit 1 - "I will keep frozen vegetables available for the kit." 2 - "I will replace food items in the kit every 9 months." 3 - "I will have a 2-day supply of food in the kit." 4 - "I will purchase canned fruit for the kit."

4 - "I will purchase canned fruit for the kit." Rational 1 - The nurse should reinforce that the participants should use nonperishable food items when preparing a home disaster kit. 2 - The nurse should reinforce that it is important to replace food items in the home disaster kit every 6 months to ensure food is suitable for eating. 3 - The nurse should reinforce that a home disaster kit should contain a 3-day supply of food per person at minimum. If possible, participants should acquire a 3- to 6-week supply. 4 - A home disaster kit should include nonperishable food items, which require no cooking or preparation and little water. Therefore, the nurse should identify the inclusion of canned fruit as an understanding of the information.

A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first? 1 - Verify the medication with the client's medication administration record (MAR). 2 - Cleanse the eye with a damp wash cloth from the inner to the outer canthus. 3 - Have the client sit in a chair and hyperextend his neck. 4 - Apply gentle pressure to the lacrimal sac for 60 seconds.

1 - Verify the medication with the client's medication administration record (MAR) Rational 1 - Evidence-based practice indicates the first action the nurse should take when administering ophthalmic medication is to validate the client's name, the name and dosage of the medication, and the medication prescription, route, and time with the client's MAR. 2- The nurse should cleanse the client's eye with a damp wash cloth from the inner to the outer canthus prior to administering ophthalmic medication. However, evidence-based practice indicates there is another action the nurse should take first. 3 - The nurse should have the client sit in a chair and hyperextend his neck prior to administering ophthalmic medication. However, evidence-based practice indicates there is another action the nurse should take first. 4 - The nurse should apply gentle pressure to the lacrimal sac for 60 seconds after administering ophthalmic medication to prevent systemic absorption of the medication. However, evidence-based practice indicates there is another action the nurse should take first.

A newly hire nurse recognized that the unit staff and nurse manager seem to be in constant conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches when she decides that her plans are best and the unit staff is no longer trying to resolve conflict? 1 - Win-Yield 2 - Lose-Lose 3 - Win-Win 4 - Win-Lose

1 - Win-Yield Rational 1 - The nurse should identify the unit is using the win-yield approach to conflict management. With this approach, the manager is always right and the staff is no longer trying to resolve conflict, which creates an oppressed working environment on the unit. 2 - With the lose-lose approach to conflict management, there are no winners. The manager either ignores or does not accept that there is conflict and is not working toward a resolution. This approach leads to anger and frustration, which can lead to a low staff retention rate. 3 - With the win-win approach to conflict management, everyone is a winner and feels positive about the outcome. This approach values input from staff and results in improved client care and employee morale. 4 - With the win-lose approach to conflict management, the manager is always right and refuses to give others credit for ideas. This prevents staff members from providing input and doing their best at a job.

A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients. 1 - A client who has closed fractures in both arms 2 - A client who has a large, open chest wound 3 - A client who has burns to the trunk and legs 4 - A client who has a penetrating head wound

3 - A client who has burns to the trunk and legs Rational 1 - The nurse should expect this client to have a green tag because this client's injuries do not require immediate care. 2 - The nurse should expect this client to have a red tag because this client's injury poses an immediate threat to survival. 3 - The nurse should expect this client to have a yellow tag because this client's injuries require treatment that can be delayed. 4 - The nurse should expect this client to have a black tag because there is a minimal chance of survival.

A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first? 1 - A client who has partial-thickness burns to the arms and reports severe pain 2 - A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent 3 - A client who has an open fracture of the femur and a 5.1 cm (2 in) laceration of the thigh 4 - A client who is unconscious with a closed head injury and whose pupils are fixed and dilated

2 - A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent Rational 1 - A client who has partial-thickness burns to the upper extremities requires urgent care; however, the nurse should provide care to another client first. 2 - A client who has a pelvic crush injury and an absent pulse to the lower extremity has an immediate threat to life and limb and requires emergent care for survival. When using the survival approach to client care, the nurse should give priority to this client. 3 - A client who has an open fracture of the femur and a laceration of the thigh requires urgent care; however, the nurse should provide care to another client first. 4 - A client who has a closed head injury and whose pupils are fixed and dilated has a minimal chance of survival, even with intervention. Therefore, the nurse should provide care to another client first.

A nurse at a rehabilitation facility is participating in an interprofessional care conference for a client who is 1 week postoperative following an above-the-knee amputation. Which of the following is the priority for the nurse to report at the conference? 1 - The client is taking oral opioids to control pain. 2 - The client's incision site has purulent drainage. 3 - The client's home bathroom does not have grab bars. 4 - The client refuses to look at her residual limb.

2 - The client's incision site has purulent drainage. Rational 1 - The nurse should report that the client is taking oral opioids to control pain to ensure adverse effects are managed and discuss other options for pain management. However, another finding is the priority for the nurse to report at the conference. 2 - The greatest risk to this client is postoperative infection, which is indicated by the presence of purulent drainage at the incision site and can cause osteomyelitis. Therefore, this is the priority finding for the nurse to report at the conference. 3 - The nurse should report that the client's home bathroom does not have grab bars so arrangements can be made to ensure safety after discharge from the facility. However, another finding is the priority for the nurse to report at the conference. 4- The nurse should report that the client refuses to look at her residual limb to develop a plan to assist the client through the grieving process. However, another finding is the priority for the nurse to report at the conference.

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? 1 - A verbal prescription from the provider taken by the charge nurse 2 - Entry of the completion of a procedure in advance 3 - A treatment that was refused by the client 4 - Subjective findings regarding the client's pain tolerance

3 - A treatment that was refused by the client Rational 1 - The nurse should only enter verbal prescriptions received directly from the provider. Therefore, the charge nurse should not document this verbal prescription. 2 - The nurse should document activities or events after the event has occurred to ensure accuracy. 3 - The nurse should document treatments that were omitted due to client refusal in the medical record. 4 - The nurse should use objective, rather than subjective, findings and observations when documenting the client's pain status.

A nurse is reinforcing teaching about home safety with an older adult client. Which of the following client statements indicates an understanding of the teaching? 1 - "I will keep the temperature in my refrigerator at 45 degrees Fahrenheit." 2 - "I should secure extension cords to the floor with transparent tape." 3 - "I should participate in a supervised exercise program." 4 - "I will limit driving to the evening hours after traffic has slowed."

3 - "I should participate in a supervised exercise program." Rational 1 - The nurse should reinforce that bacteria can grow and food can spoil when kept at temperatures greater than 4.4º C (40º F). 2 - The nurse should reinforce to secure cords carrying an electric current to the floor with electrical tape to reduce the risk of fire. The nurse should instruct the client to secure cords against baseboards, if possible, to avoid tripping on them or breaking the wires within the cords by walking or placing furniture on them. 3 - The nurse should instruct the client to participate in a supervised exercise program regularly to maintain joint flexibility, muscle strength, and balance, and reduce the risk for falls. 4 - The nurse should instruct the client to drive during daylight hours, because age-related changes to the eyes can cause reduced accommodation to light and decreased peripheral vision.

A nurse is delegating tasks to assistive personnel (AP). Which of the following statements by the nurse includes the five rights of delegation? 1 - "Take the vital signs of the clients in rooms 226 through 232 and evaluate any changes." 2 - "Turn the client in room 621 to prevent pressure areas on his hip bones and assess for edema." 3 - "Perform the glucose checks on time and replace the glucometer back into the charger when you finish." 4 - "Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath."

4 - "Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath." Rational 1 - This statement does not include the circumstance, supervision, or a task appropriate for an AP. 2 - This statement does not include direction, supervision, or a task appropriate for an AP. 3 - This statement does not include the correct client, circumstance, or supervision. 4 - The nurse should identify that the five rights of delegation include right task, circumstances, person, direction, communication, and level of supervision. This statement contains all five rights of delegation and is an appropriate task for the nurse to delegate to an AP.

A charge nurse in a long-term care facility is reviewing massage boards in various client rooms. Which of the following information should the charge nurse request one of the nurses remove from the client's board? 1 - "Vital signs twice daily" 2 - "I&O q4h" 3 - "Laboratory test at 0600" 4 - "Hospice nurse visit at 1600"

4 - "Hospice nurse visit at 1600" Rational 1- HIPAA does not prohibit posting routine scheduled nursing tasks, such as obtaining vital signs, on message boards. 2 - HIPAA does not prohibit posting routine scheduled nursing tasks, such as intake and output, on message boards. 3 - HIPAA does not prohibit posting routine laboratory tests on message boards, as long as the results of the test are not included. 4 - The charge nurse should request removal of any information concerning the client's medical diagnosis and/or treatment from message boards. HIPAA specifically prohibits posting a client's private health information because this violates the client's right to confidentiality.

A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator? 1 - The unit sets a goal to ask all clients upon admission if they have a living will. 2 - An additional 15 wall-mounted hand sanitizers are installed on the unit. 3 - A new standardized form is developed for peer reviews facility-wide. 4 - The facility-wide fall injury rate for the previous quarter is 3%.

4 - The facility-wide fall injury rate for the previous quarter is 3%. Rational 1 - This is a goal, rather than an outcome indicator that provides actual evidence of quality of care. 2 - This reflects resource management and is not an indicator that provides actual evidence of quality of care. 3 - This is an example of implementation of standards and is not an indicator that provides actual evidence of quality of care. 4 - This is a valid outcome indicator because it provides statistical evidence related to quality of care.

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? 1 - "I will run extension cords under area rugs." 2 - "I will place broken glass in a plastic bag for disposal." 3 - "I will paint the edge of each of my entry steps a different color." 4 - "I will keep my water heater set at 130 degrees Fahrenheit."

3 - "I will paint the edge of each of my entry steps a different color." Rational 1 - This statement by the client does not indicate an understanding of the teaching. Extension cords and area rugs create a risk for falls and should not be used. 2 - This statement by the client does not indicate an understanding of the teaching. The client should place broken glass in a paper bag for disposal. 3 - This statement by the client indicates an understanding of the teaching. Painting the edge of each entry step a different color provides contrast, making it easier for the client to see. 4 - This statement by the client does not indicate an understanding of the teaching. Water heaters should be set below 48.9° C (120° F) to prevent burn injuries.

A newly licensed nurse is caring for a client who requires a straight catheterization. The nurse informs the charge nurse that he has only observed the procedure on two occasions. Which of the following responses should the charge nurse make? 1 - "You should review the policy manual before performing the procedure." 2 - "I'll assign this task to another nurse and you can observe." 3 - "Let's discuss the procedure and I'll assist you with it the first time." 4 - "I suggest that you seek help from one of your more experienced colleagues."

3 - "Let's discuss the procedure and I'll assist you with it the first time." Rational 1 - This response does not ensure that the nurse receives the level of instruction and supervision needed to provide safe, effective care. 2 - Observation will not provide the newly licensed nurse with the instruction needed to perform the task in the future. 3 - With this response, the charge nurse takes responsibility for coaching the newly licensed nurse by providing direct instruction and ensuring safe, effective care for the client. 4 - The charge nurse should take direct responsibility for correcting the newly licensed nurse's knowledge deficit.

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? 1 - The risk of lead poisoning is greatest in 10-year-old children. 2 - The supine position is the safest for sleeping infants. 3 - Falls are the leading cause of injury in preschoolers. 4 - Air-popped popcorn is a recommended snack for toddlers.

2 - The supine position is the safest for sleeping infants. Rational 1 - Children younger than 6 years old are at greatest risk for lead poisoning due to placing objects in their mouths. 2 - The nurse should reinforce placing an infant in the supine position is recommended by the American Academy of Pediatrics to decrease the risk of sudden infant death syndrome (SIDS). 3 - Injury from falls decreases in preschoolers because of improved coordination and motor skills as they move out of the clumsy toddler years. 4 - Popcorn increases the risk for choking in the toddler and the nurse should reinforce with the parents that it should be avoided as a snack.

A nurse is caring for a client who is recovering following a total hip arthroplasty. The nurse receives a telephone call from the client's call from the client's sister requesting information about the client's status. Which of the following actions should the nurse take? 1 - Check the client's medical record to determine who the health care surrogate is. 2 - Transfer the call to the client. 3 - Ask the caller how urgent it is to have this information. 4 - Transfer the call to the charge nurse.

2 - Transfer the call to the client. Rational 1 - The health care surrogate is able to make decisions regarding health care issues when the client is not able to do so, but there is no indication that the client is unable to make decisions.l 2- The nurse should allow the client to provide information to whomever they choose. This action protects the client's right to privacy under HIPAA. 3 - The nurse should not disclose the information to the caller, regardless of the urgency. Disclosure of information without the client's consent is a violation of HIPAA. 4 - The nurse should not transfer the call to the charge nurse. The charge nurse might need to intervene if there is a complex or problematic situation with visitors; however, this situation falls within the nurse's responsibilities.

A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides? 1 - Select a white background with light-colored text. 2 - Use sentences that have a maximum of six words. 3 - Limit the number of lines to 10 per slide. 4 - Place slide animations or video clips on each slide.

2 - Use sentences that have a maximum of six words. Rational 1 - When developing effective slides for a slide presentation, the nurse should use a background and text that are contrasting and therefore, easier for the audience to read. 2 - When developing effective slides for a slide presentation, the nurse should keep sentences short and limit the number of words to five or six per sentence. 3 - When developing effective slides for a slide presentation, the nurse should limit the number of lines to five or six per slide. 4 - When developing effective slides for a slide presentation, the nurse should limit the use of animations and video clips which, if overused, can decrease the effectiveness of the presentation.

A nurse is reinforcing discharge teaching with a client who has a new prescription for home oxygen therapy. Which of the following client statements indicates understanding of the teaching? 1 - "I will schedule monthly maintenance appointments for my equipment." 2 - "I will use a petroleum-based moisturizer if my nostrils begin to feel chapped." 3 - "I will keep the oxygen concentrator 5 feet away from the fireplace." 4 - "I will store my extra oxygen cylinders under the bed."

1 - "I will schedule monthly maintenance appointments for my equipment." Rational 1 - The client should schedule monthly appointments for maintenance of oxygen equipment to ensure it is working correctly. 2 - The client should use a water-soluble moisturizer if nostrils begin to feel chapped. Petroleum-based moisturizer is flammable and should be avoided. 3 - The client should keep the oxygen concentrator at least 2.4 m (8 feet) away from a heat source. 4 - The client should secure oxygen cylinders in an upright position. Prior to storing the extra cylinders under the bed, they would need to be placed on their side. This is a safety risk and should be avoided.

A charge nurse in a skilled care facility identifies an increased rate of client falls. Which of the following statements to the nursing staff indicates the charge nurse is addressing the problem with an autocratic leadership style? 1 - "I've made it mandatory for all nursing staff to attend an educational session on reducing client falls." 2 - "I know this problem affects our entire nursing staff, so let's work together towards a goal of decreased client falls." 3 - "I'm turning over the problem of increased client falls to you as the nursing staff to address." 4 - "I'd like to have input from the entire nursing staff on how to address the problem of client falls."

1 - "I've made it mandatory for all nursing staff to attend an educational session on reducing client falls." Rational 1 - This statement indicates an autocratic style of leadership. An autocratic leader makes independent decisions about how to address a problem without seeking input from nursing staff. 2 - This statement indicates a transformational style of leadership. A transformational leader tries to promote motivation and commitment from the nursing team towards a common goal. 3 - This statement indicates a laissez-faire style of leadership. A laissez-faire leader lets the nursing staff address a problem without providing any supervisory input. 4 - This statement indicates a democratic style of leadership. A democratic leader seeks input from nursing staff so that everyone is involved in the problem-solving process.

A nurse is assisting with the care of a client who has terminal cancer and is receiving chemotherapy. The client tells the nurse that she is only continuing treatment for her family's sake. Which of the following responses should the nurse make? 1 - "Let's talk about your reasons for continuing treatment." 2 - "You should talk to a social worker about your situation." 3 - "I'll get the chaplain to come speak with you about your thoughts and feelings." 4 - "I know you are tired of this treatment, but you are right to think of your family first."

1 - "Let's talk about your reasons for continuing treatment." Rational 1 - This response by the nurse is therapeutic because it focuses the conversation on the key components of the message and allows the client to discuss the treatment and any concerns she is having. The nurse also validates the client's feelings and thoughts, which enhances trust between the nurse and the client. 2 - This statement is dismissive of the client's concerns and is nontherapeutic. 3 - This statement is dismissive of the client's concerns and is nontherapeutic. 4 - This statement expresses the nurse's opinion regarding the client's decision and is nontherapeutic.

A charge nurse is talking with two assistive personnel (AP) who are angry about the way lunch breaks are scheduled on the unit. Which of the following statements by the charge nurse demonstrates the use of compromise? 1 - "You can take turns going to lunch first every other week." 2 - "Whoever has seniority should go to lunch first." 3 - "You should try to work out the lunch schedule between the two of you." 4 - "Can we discuss this tomorrow? I need some time to think about the schedule."

1 - "You can take turns going to lunch first every other week." Rational 1 - Successful negotiation through compromise requires that each party give up something. The charge nurse should suggest an alternating lunch schedule, in which each party gives up what they want only part of the time. This use of compromise results in a win-win outcome for all parties. 2 - This does not address resolution of the conflict. The nurse is using force to resolve the conflict resulting in a win-lose outcome. Therefore, one person gets what they want at the expense of the other. 3 - This does not address resolution of the conflict. The charge nurse is avoiding management of the conflict. 4 - This is an example of avoidance, in which the charge nurse does not address the underlying conflict.

A nurse enters a client's room at the beginning of a shift. Which of the following findings requires intervention by the nurse? 1 - A capped bottle of sterile water that was opened 36 hr ago 2 - A urinary catheter drainage bag that is hanging on the lower portion of the bed frame 3 - A peripheral IV catheter that was inserted 2 days ago 4 - A wound dressing that requires frequent changes and is secured using Montgomery straps

1 - A capped bottle of sterile water that was opened 36 hr ago Rational 1 - The nurse should discard a bottle of sterile water that was opened more than 24 hr ago. 2 - The nurse should hang the urinary catheter drainage bag below the level of the client's bladder. This finding does not require intervention by the nurse. 3 - The nurse should recommend that an IV site be changed if there are indications of contamination or complications are present. This finding does not require intervention by the nurse. 4 - The nurse should use Montgomery straps to secure a dressing that requires frequent changes to reduce skin irritation and promote client comfort. This finding does not require intervention by the nurse.

A nurse is assisting with the care of a client who suddenly becomes unconscious and requires emergency surgery. The client does not have advanced directives and the only family member available is the client's 14-year-old daughter. Which of the following actions should the nurse plan to take? 1 - Transport the client to the operating room with implied consent. 2 - Call the 14-year-old daughter to obtain informed consent. 3 - Send an urgent request to the facility's ethics board. 4 - Obtain a court order for the emergency surgery.

1 - Transport the client to the operating room with implied consent. Rational 1 - In an emergency, if it is not possible to obtain informed consent from the client, consent is implied because it is assumed that the client would want the medically necessary surgical treatment. 2 - A 14 year old is not legally considered competent to provide surgical consent for the client. 3 - The need for immediate surgery is a legal situation, rather than an ethical situation. Therefore, the nurse should not refer the case to the facility's ethics board. 4 - Obtaining a court order delays the client's need for treatment and is not necessary in an emergency situation.

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 interprofessional care conference? 1 - An infant who has cystic fibrosis and is continuing to lose weight 2 - An infant who has pneumonia and is receiving IV antibiotics 3 - A school-age child who has sickle cell disease and is scheduled to receive a blood transfusion 4 - A school-age child who has spina bifida and whose parent needs to learn to perform intermittent catheterization

1 - An infant who has cystic fibrosis and is continuing to lose weight Rational 1 - When using Maslow's hierarchy of needs, the nurse should determine that this client is the priority for an interprofessional care conference to meet the client's need for food and fluids. This client is at risk for inadequate nutrition resulting in impaired growth. Addressing this problem requires a multidisciplinary approach, including a dietitian. 2 - Although this client could benefit from an interprofessional care conference, another client is the priority. The client's current need can be addressed by the nursing staff. 3 - Although this client could benefit from an interprofessional care conference, another client is the priority. The client's current need can be addressed by the nursing staff. 4 - Although this client could benefit from an interprofessional care conference, another client is the priority. The client's current need can be addressed by the nursing staff.

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? 1 - Ask the client to identify his goals for recovery. 2 - Select interventions to match the priority client needs. 3 - Reinforce information with the client about expected treatment outcomes. 4 - Recommend referrals to address the client's needs.

1 - Ask the client to identify his goals for recovery. Rational 1 - The first action the nurse should take using the nursing process is to collect data from the client. By asking the client to identify his goals for recovery, the nurse helps ensure the plan of care reflects issues that are important to both the client and health care team. 2 - The nurse should select interventions to match the priority client needs to ensure nursing actions promote client recovery; however, there is another action the nurse should take first. 3 - The nurse should reinforce information with the client about expected treatment outcomes to promote client understanding of additional interventions that might be required; however, there is another action the nurse should take first. 4 - The nurse should recommend referrals to address the client's needs to promote interprofessional collaboration; however, there is another action the nurse should take first.

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 1 - Begin the timed collection by discarding the first specimen. 2 - Post the times for urine collection above the toilet in the client's bathroom. 3 - Document volume estimations of missed voids. 4 - Obtain a clean specimen collection container for use during the test. 5 - Remove feces or toilet paper that is in the specimen collection container.

1 - Begin the timed collection by discarding the first specimen. 2 - Post the times for urine collection above the toilet in the client's bathroom. 4 - Obtain a clean specimen collection container for use during the test. Rational 1 - Begin the timed collection by discarding the first specimen is correct. The nurse should begin the timed collection when the client voids. This nurse should discard the first specimen. 2 - Post the times for urine collection above the toilet in the client's bathroom is correct. The nurse should post information about the urine collection testing, including the start and end time, in a prominent place to prevent accidental discarding of urine. 3 - Document volume estimations of missed voids is incorrect. In the event a client misses placing a void into the specimen collection container, the test must be restarted. 4 - Obtain a clean specimen collection container for use during the test is correct. The nurse should obtain a clean container for the client to use during the testing period to avoid contamination of the specimen. 5 - Remove feces or toilet paper that is in the specimen collection container is incorrect. Feces or toilet paper will contaminate the specimen. The nurse should instruct the client to defecate prior to voiding and to place toilet paper into the toilet bowl, rather than the collection container.

A nurse at a rehabilitate facility is supervising a newly hired assistive personnel (AP) during the transfer of a client from the bed to a chair. Which of the following actions by the AP demonstrates safe transfer technique? 1 - Bends at the knees 2 - Twists at the waist 3 - Maintains a narrow stance 4 - Leans away from the client

1 - Bends at the knees Rational 1 - Bending at the knees increases stability by using larger muscles and demonstrates safe transfer technique. 2- Twisting at the waist increases the risk of injury to the lumbar vertebrae and back muscles. 3 - A narrow stance reduces stability and increases the risk of injury to the AP and the client. 4 - The AP should lean forward toward the client while flexing at the hip, to reduce the distance between the client and the AP to prevent injury.

A charge nurse is discussing legal issues with a newly licensed nurse. Which of the following actions should the charge nurse identify as negligence? 1 - Failing to provide one-to-one observation for a client who is suicidal. 2 - Speaking negatively about a provider's abilities to a client's family. 3 - Signing the client's medical record as an LPN before taking the NCLEX-PN. 4 - Inserting a urinary catheter in a competent client without consent.

1 - Failing to provide one-to-one observation for a client who is suicidal. Rational 1 - Failure to provide care according to established standards of care is negligence. Failing to provide one-to-one observation to a client who is suicidal puts the client at risk for self-injury. 2 - Speaking negatively about a provider's abilities to a client's family is defamation of character. 3 - Signing the client's medical record as an LPN when the nurse does not have a PN license is fraud. 4 - Inserting a urinary catheter without the client's consent is battery.

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 interprofessional health care team should the nurse consult to assist the client with glucose management? 1 - Occupational therapist 2 - Registered dietitian 3 - Social worker 4 - Speech therapist

2 - Registered dietitian Rational 1 - The nurse should arrange a consult with an occupational therapist for a client who is having difficulty performing activities of daily living (ADLs). 2 - The nurse should arrange a consult with a registered dietitian to help the client with meal and snack plans, which will ensure stable blood glucose levels. 3 - The nurse should arrange a consult with a social worker for a client who requires community resources to help manage an illness or disease, such as affording the costs of medications. 4 - The nurse should arrange a consult with a speech therapist for a client who is experiencing language or swallowing difficulties.

A nurse is observing an assistive personnel (AP) provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks? 1 - Making a surgical bed for a client returning from surgery 2 - Emptying a client's urine collection bag 3 - Brushing a client's teeth 4- Administering a commercially prepared enema

1 - Making a surgical bed for a client returning from surgery Rational 1- Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, such as blood or wound drainage. It is not necessary to use gloves when making an unoccupied surgical bed. Therefore, this is a waste of supplies and requires intervention by the nurse. 2 - Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, including urine. Therefore, the AP should apply gloves prior to emptying a client's urine collection bag. 3 - Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, including saliva. Therefore, the AP should apply gloves prior to brushing a client's teeth. 4 - Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, including fecal matter. Therefore, the AP should apply gloves prior to administering a commercially prepared enema.

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? 1 - Place a tag on the IV pump. 2 - Report the malfunctioning IV pump to the risk manager. 3 - Calculate the manual IV drip rate. 4 - Call housekeeping to pick up the IV pump.

1 - Place a tag on the IV pump. Rational 1 - The nurse should place a tag on the malfunctioning IV pump and remove it from service to prevent injury to the client and others. 2 - The nurse should report the malfunctioning IV pump to the charge nurse. 3 - The nurse should assist with the replacement of the malfunctioning unit with a new IV pump and continue the infusion. 4 - The nurse should call the clinical engineer to pick up 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)? 1 - Provide postmortem care. 2 - Insert a nasogastric tube. 3 - Obtain a specimen for a wound culture. 4 - Instruct a client on the use of an incentive spirometer.

1 - Provide postmortem care. Rational 1 - The nurse should assign the AP to provide postmortem care because this task is within the AP's range of function. 2 - The nurse should not assign the AP to insert a nasogastric tube. This task is an invasive procedure and is outside the AP's range of function. 3 - The nurse should not assign the AP to obtain a specimen for a wound culture because this task is an invasive procedure which requires sterile technique. Therefore, this task is outside the AP's range of function. 4 - The nurse should not assign the AP to instruct a client on the use of an incentive spirometer because performing client education is outside the AP's range of function.

A charge nurse notices a nurse on the unit arriving to work 30 min late. The nurse appears unkempt and has slurred speech. Which of the following actions should the charge nurse take first? 1 - Reassign the nurse's clients to another nurse. 2 - Support the nurse manager in reporting the incident to the board of nursing. 3 - Offer emotional support to the nurse. 4 - Document the incident for the nurse manager.

1 - Reassign the nurse's clients to another nurse. Rational 1 - The greatest risk is to allow an impaired nurse to care for clients. Therefore, the first action the charge nurse should take is to remove the nurse from the unit and reassign the nurse's clients to another nurse to prevent harm. 2 - In some states, it is mandatory for nurses to report unprofessional conduct to the board of nursing. The charge nurse should support the nurse manager in reporting the incident to the board of nursing to protect clients from harm; however, there is another action the charge nurse should take first. 3 - The charge nurse should offer emotional support and encourage the nurse to seek assistance for a possible substance use disorder; however, there is another action the charge nurse should take first. 4 - The charge nurse should report the incident to the report manager and document the incident while ensuring the documentation is objective and factual; however, there is another action the charge nurse should take first.

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? 1 - Review evidence-based practice data related to bladder scanner use. 2 - Compare the cost of indwelling urinary catheters with that of a bladder scanner. 3 - Conduct a chart audit to determine previous outcome trends in bladder scanner use. 4 - Gather a consensus of provider opinions about the use of bladder scanners at the facility

1 - Review evidence-based practice data related to bladder scanner use Rational 1 - To facilitate the best client outcomes, the performance improvement team should review available evidence-based practice data related to this task. This should provide the most accurate and comprehensive information on which to base policy and procedure decisions. 2 - Due to the high incidence of infections among clients who have catheters, the cost of a bladder scanner should not be an influential factor in the development of a policy and procedure. 3 - A chart audit does not provide relevant data for developing a policy and procedure for this task. 4 - While the nurse should include the providers in the change process, their opinions do not provide relevant data for developing a nursing policy and procedure for this task.

A nurse is participating in a peer evaluation system based on overall performance of its nursing staff. Which of the following strategies ensures that the peer evaluation process is impartial and fair? 1 - Uses the same objective measurement tool for all nurses 2 - Reviews personnel files for counseling forms and verbal or written warnings 3 - Designates experienced nurses to perform all peer evaluations 4 - Excludes nurses from the process if they are uncomfortable evaluating their peers

1 - Uses the same objective measurement tool for all nurses Rational 1 - An objective measurement tool based on established standards provides consistent criteria for evaluation and decreases the amount of subjectivity. 2 - This strategy focuses on isolated incidents, rather than overall performance. 3 - Amount of nursing experience is unrelated to objectivity in peer evaluations. The nurses who contribute to a peer evaluation should have the same nursing qualifications as the nurse being reviewed. 4 - For an individual nurse's peer reviews to be fair, other nurses should not be excluded from the process because they are uncomfortable with the system. While each nurse might only provide a peer review for a few selected other nurses, it is important for all nurses to be engaged and involved in the process.

A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? Select all 1 - Select an interpreter who is the same gender as the client. 2 - Ask the client's family members to interpret the information. 3 - Ensure interpreters provided by the facility have knowledge of medical terminology. 4 - Obtain informed consent from the client prior to requesting an interpreter. 5 - Choose an interpreter from the same ethnic background as the client.

1 - Select an interpreter who is the same gender as the client. 3 - Ensure interpreters provided by the facility have knowledge of medical terminology. 5 - Choose an interpreter from the same ethnic background as the client. Rational 1 - Select an interpreter who is the same gender as the client is correct. The nurse should select an interpreter who is the same gender as the client to avoid embarrassment. 2 - Ask the client's family members to interpret the information is incorrect. Family members may not understand medical terminology and may not interpret the information completely or accurately. 3 - Ensure interpreters provided by the facility have knowledge of medical terminology is correct. To accurately relay medical information, interpreters should have specialized medical training. 4 - Obtain informed consent from the client prior to requesting an interpreter is incorrect. Informed consent is used for specific medical and surgical procedures. Obtaining the use of an interpreter would entail expressed or implied consent. 5 - Choose an interpreter from the same ethnic background as the client is correct. The nurse should select an interpreter that is from the same ethnic background as the client to prevent possible conflicts and differences in dialect.

A nurse is discussing time management with a newly licensed nurse. Which of the following actions should the nurse recommend to organize daily assigned client tasks? 1 - Setting goals 2 - Assignment sheet 3 - Critical pathway 4 - Flow sheet

1 - Setting goals Rational 1 - The nurse should establish goals, according to assigned clients' needs and plans of care, at the beginning of each shift as an effective method of time management. 2 - The charge nurse should use an assignment sheet to communicate client care assignments. The nurse should refer to the assignment sheet to identify which clients she is assigned for the shift. However, this is not a method of time management. 3 - The nurse should refer to the critical pathway to identify recommended treatments and outcomes for a client who has a specific diagnosis. However, this is not a method of time management. 4 - The nurse should use a flow sheet to document the completion of routine client care tasks. However, this is not a method of time management.

A nurse is assisting with the discharge of a client who has a new permanent colostomy. The client expresses concern about learning to care of the appliance and obtaining supplies discretely. Which of the following actions should the nurse take? Select all 1 - Suggest that the client join an ostomy support group. 2 - Arrange a follow-up appointment with an enterostomal therapy nurse. 3 - Provide the client with the name and number of an ostomy supply delivery service. 4 - Recommend that the client's discharge be postponed until concerns are resolved. 5 - Request a social work referral for the client to discuss financial concerns

1 - Suggest that the client join an ostomy support group. 2 - Arrange a follow-up appointment with an enterostomal therapy nurse. 3 - Provide the client with the name and number of an ostomy supply delivery service. 5 - Request a social work referral for the client to discuss financial concerns Rational 1 - Suggest that the client join an ostomy support group is correct. An ostomy support group, such as those affiliated with the United Ostomy Association, can provide helpful information for clients who have a new ostomy. 2 - Arrange a follow-up appointment with an enterostomal therapy nurse is correct. An enterostomal therapy nurse will follow up with the client regarding ostomy care. 3 - Provide the client with the name and number of an ostomy supply delivery service is correct. The nurse should provide the client with initial ostomy supplies and inform the client of medical supply companies from which he can obtain future supplies or have them delivered discretely. 4 - Recommend that the client's discharge be postponed until concerns are resolved is incorrect. Unless the client experiences complications, the nurse should work with the interprofessional discharge planning team to meet the client's needs prior to the scheduled discharge. The client might continue to experience apprehension about caring for a new appliance; however, this can be addressed by a home health nurse. In many cases, the ostomy supply company has an educator on staff to assist the client as he gets more comfortable with the new appliance. 5 - Request a social work referral for the client to discuss financial concerns is correct. The nurse should request a referral to a social worker. A social worker can assist the client with identifying community resources and providing financial counseling.

A nurse in an outpatient clinic for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility? 1 - The client develops command hallucinations. 2 - The client displays transference toward the nurse. 3 - The client reveals a family history of schizophrenia. 4 - The client expresses feelings of low self-esteem.

1 - The client develops command hallucinations. Rational 1 - Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility. 2 - The client's display of transference toward the nurse is not an indication the client should be transferred to an acute care facility. 3 - Although it is important that the client understand the etiology and family history of the condition, this is not an indication that the client should be transferred to an acute care facility. 4 - Feelings of low self-esteem are an expected finding in a client who has schizophrenia. Therefore, this does not indicate a need for the client to be transferred to an acute care facility.

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? 1 - The nurse assists a client in communicating end-of-life decisions to the provider. 2 - The nurse personalizes client medication information to reinforce client teaching. 3 - The nurse implements a turn schedule to prevent client skin breakdown. 4 - The nurse consistently assigns the same staff to a client who has dementia.

1 - The nurse assists a client in communicating end-of-life decisions to the provider. Rational 1 - The nurse acts in the role of client advocate when protecting the client's legal and ethical rights. 2 - The nurse acts in the role of client educator when reinforcing client teaching. 3 - The nurse acts in the role of caregiver when providing care to prevent health problems. 4 - The nurse acts in the role of manager when making staff assignments that best meet the needs of the client.

A nurse is delegating collection of a random stool specimen to an assistive personnel (AP). Which of the following information should the nurse provide? 1 - Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal. 2 - Collect pus from the stool with a sterile swab and place it in a sterile test tube. 3 - Place chlorhexidine in the client's commode before he provides the sample. 4 - Double-bag the specimen if it must be placed in a refrigerator containing medication.

1 - Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal. Rational 1 - The nurses should instruct the AP to use one to two tongue blades to move the stool specimen to the collection container. After transferring the stool, the AP should wrap the tongue blades in a paper towel before discarding them in the trash to prevent others from accidentally touching the contaminated surfaces. 2 - The nurse should recognize that a sterile swab and test tube are required when collecting a stool for culture, which is not a task that is within the AP's range of function. 3 - The nurse should instruct the AP to have the client defecate in a clean bedpan or bedside commode to provide the stool sample. The AP should not contaminate the stool with chlorhexidine. 4 - The nurse should remind the AP to take the specimen to the laboratory immediately. Some specimens can be refrigerated temporarily, but never in the same location as food or medicine.

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? 1 - A client who has a history of migraine headaches and reports an aura 2 - A client who has new onset atrial fibrillation and reports lightheadedness 3 - A client who requires a Doppler for pedal pulse measurement due to poor circulation 4 - A client who requires droplet isolation precautions for pneumonia

2 - A client who has new onset atrial fibrillation and reports lightheadedness Rational 1 - Experiencing an aura prior to the development of a migraine headache is an expected occurrence and does not indicate the client is in any distress. Therefore, it is acceptable for the AP to measure this client's routine vital signs. 2 - Clients who have new onset atrial fibrillation often experience lightheadedness, tachycardia, and hypotension. Because the client's condition is unstable and might require nursing judgment, the nurse should plan to measure the client's vital signs since these tasks are outside the AP's range of function. 3 - Requiring a Doppler for pedal pulse measurement is an expected finding for a client who has poor circulation and does not indicate the client is in any distress. Therefore, it is acceptable for the AP to measure this client's routine vital signs. 4 - Requiring droplet isolation precautions can be part of routine management of pneumonia and does not indicate the client is in any distress. Therefore, it is acceptable for the AP to measure this client's routine vital signs while adhering to the isolation restrictions.

A nurse is assisting with the selection of clients to discharge to make beds available following a tornado in the community. Which of the following clients should the nurse recommend for discharge? 1 - A client who was admitted 24 hr ago for fluid volume deficit and now has a serum potassium level of 3.1 mEq/L 2 - A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago 3 - A client who has uterine cancer and had intracavity placement of radiation 30 hr ago 4 - A client who was admitted 12 hr ago for heatstroke and has been rehydrated with 2,000 mL of 0.9 % sodium chloride

2 - A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago Rational 1 - A client who has a serum potassium level of 3.1 mEq/L has hypokalemia and is at risk for cardiac dysrhythmias. The nurse should not recommend this client for discharge. 2 - A client who had an appendectomy without complications is often discharged the day of or the day after surgery. The nurse should recommend this client for discharge because this client has a low risk for an adverse event. 3 - A client who has an internal radiation implant is a hazard to others as long as the implant is in place. The nurse should not recommend this client for discharge. 4 - A client who experienced a heatstroke is at risk for seizures, pulmonary edema, or liver failure. The nurse should not recommend this client for discharge.

A nurse on a pediatric unit is assisting with the care of four clients. Which of the following should the nurse plan to see first? 1 - An infant who has rotavirus and watery diarrhea 2 - A preschooler who has respiratory syncytial virus and is wheezing 3 - A toddler who is in a hip spica cast and has had a bowel movement 4 - An adolescent who has sickle cell disease and is requesting pain medication

2 - A preschooler who has respiratory syncytial virus and is wheezing Rational 1 - The nurse should see this client to check and maintain skin integrity and fluid balance. However, another client is the priority. 2 - When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority client is the preschooler who is wheezing because this client is at risk for a possible airway obstruction. 3 - The nurse should see this client to check and maintain skin and cast integrity. However, another client is the priority. 4 - The nurse should see this client to determine the client's level of pain and prescription for pain medication. However, another client is the priority.

A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse include? Select all 1 - Restrict sodium intake to 4 g per day. 2 - Administer furosemide 40 mg PO daily. 3 - Place the client in supine position when in bed. 4 - Apply oxygen to keep SpO2 greater than 95%. 5 - Obtain daily weight.

2 - Administer furosemide 40 mg PO daily. 4 - Apply oxygen to keep SpO2 greater than 95%. 5 - Obtain daily weight. Rational 1 - Restrict sodium intake to 4 g per day is incorrect. A client who has heart failure should receive less than 1.5 g of sodium per day. 2 - Administer furosemide 40 mg PO daily is correct. A client who has heart failure can benefit from a loop diuretic, such as furosemide, to reduce pulmonary and peripheral edema. 3 - Place the client in supine position when in bed is incorrect. A client who has heart failure should be placed in semi- to high-Fowler's position when in bed to decrease dyspnea. 4 - Apply oxygen to keep SpO2 greater than 95% is correct. A client who has heart failure might require supplemental oxygen to maintain an adequate SpO2 level. A SpO2 greater than 95% is an acceptable outcome. 5 - Obtain daily weight is correct. The nurse should obtain a daily weight for a client who has heart failure to provide data about fluid balance.

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? 1 - Client medicated with morphine 30 mg PO for report of right shoulder pain rated 7 on a scale of 0 to 10. 2 - Administered 10.0 u of insulin SQ to client for elevated glucose level. 3 - Reinforced to client to turn, cough, and deep breathe every 2 hr while awake. Client verbalized understanding. 4 - Reported client's oral temperature 39.7° C (103.5° F) to provider.

2 - Administered 10.0 u of insulin SQ to client for elevated glucose level. Rational 1 - This entry represents accurate and complete documentation. 2 - This entry requires intervention by the charge nurse for the use of unapproved abbreviations (u, SQ), a trailing zero (10.0), and incomplete information including type of insulin, how it was administered, and glucose level. 3 - This entry represents accurate and complete documentation. 4 - This entry represents accurate and complete documentation.

A nurse is assisting with the discharge of a client who was in a motor-vehicle crash 24 hr ago. The client tells the nurse, "My vision seems blurry, and I am having difficulty speaking clearly." Which of the following actions should the nurse take first? 1 - Document the client's statement in the medical record. 2 - Check the client for indications of increased intracranial pressure. 3 - Notify the charge nurse of the client's statement. 4 - Instruct the client to remain in bed with the head elevated.

2 - Check the client for indications of increased intracranial pressure Rational 1 - The nurse should document the client's statement in the medical record to indicate the change in the client's condition. However, there is another action the nurse should take first. 2 - The first action the nurse should take using the nursing process is to collect data from the client. By checking the client for indications of increased intracranial pressure, the nurse can determine if the client has any neurological deficits and identify findings to report to the charge nurse and the provider. 3 - The nurse should notify the charge nurse, who will inform the provider of the client's statement. However, there is another action the nurse should take first. 4 - The nurse should instruct the client to remain in bed with the head elevated to prevent any further increase in intracranial pressure. However, there is another action the nurse should take first.

A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Which of the following actions should the nurse take first? 1 - Notify the charge nurse and the client's provider. 2 - Check the client for injuries. 3 - Request help to assist the client back to bed. 4 - Complete an incident report.

2 - Check the client for injuries. Rational 1 - The nurse should notify the charge nurse and the provider that the client has fallen; however, there is another action the nurse should take first. 2 - When using the nursing process, the nurse should identify that the priority action is to collect data from the client. Therefore, the first action the nurse should take is to check the client for injury. 3 - The nurse should assist the client back to bed when help arrives, after ensuring no further injury would be caused during the transfer; however; there is another action the nurse should take first. 4 - The nurse should complete an incident report of the occurrence; however, there is another action the nurse should take first.

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? 1 - Encourage nursing staff to read research articles about advancements in wound care. 2 - Develop a spreadsheet to prepare a budget for wound care supplies. 3 - Arrange for nursing staff to attend a wound care conference through teleconferencing. 4 - Prepare a slide presentation about recognizing wound infections.

2 - Develop a spreadsheet to prepare a budget for wound care supplies. Rational 1 - The nurse should encourage nursing staff to read research articles to promote evidence-based practice; however, this action does not ensure that cost-effective care is provided. 2 - The nurse should use a spreadsheet to manage numerical data for the preparation of a budget. The use of a spreadsheet allows the nurse to analyze this data to ensure that cost-effective care is provided to clients. 3 - The nurse should use teleconferencing to provide educational and collaboration opportunities for nursing staff; however, this action does not ensure that cost-effective care is provided. 4 - The nurse should use a slide presentation to provide staff education; however, this action does not ensure that cost-effective care is provided.

A nurse is assisting with the admission of a client who reports that she signed advanced directives during a previous admission. Which of the following actions should the nurse take? Select all 1 - Require the client to complete new advance directives for this admission. 2 - Document in the client's medical record that she has advance directives. 3 - Ensure that copies of the client's advance directives are located in her chart. 4 - Inform the oncoming nurse of the client's advance directives during change-of-shift report. 5 - Contact the facility chaplain to discuss the advance directives with the client.

2 - Document in the client's medical record that she has advance directives. 3 - Ensure that copies of the client's advance directives are located in her chart. 4 - Inform the oncoming nurse of the client's advance directives during change-of-shift report. Rational 1 - Require the client to complete new advance directives for this admission is incorrect. Having advance directives is the client's right, not a requirement. 2 - Document in the client's medical record that she has advance directives is correct. According to the Patient Self-Determination Act, the client's medical record should indicate whether or not she has advance directives. 3 - Ensure that copies of the client's advance directives are located in her chart is correct. Having copies of the client's advance directives in the medical record ensures that the health care team is aware of her wishes regarding health care decisions. 4- Inform the oncoming nurse of the client's advance directives during change-of-shift report is correct. The nurse should discuss the client's advance directive status with nurses who will be directly providing client care. 5 - Contact the facility chaplain to discuss the advance directives with the client is incorrect. The nurse should not discuss the client's status with anyone who is not directly involved with the client's care without her consent.

A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take? 1 - Negotiate with the two staff nurses at the nurses' station. 2 - Encourage each staff nurse to give up something as part of the negotiation. 3 - Explain to the staff nurses that the holiday schedule is non-negotiable. 4 - Resolve the conflict with a win-yield outcome.

2 - Encourage each staff nurse to give up something as part of the negotiation. Rational 1 - The charge nurse should conduct the negotiation in a private setting where both nurses feel comfortable discussing the conflict. 2 - The charge nurse should encourage each staff nurse to give up something as part of the negotiation so that a compromise can be reached that is a win-win situation for each party. 3 - The charge nurse is displaying a win-lose negotiation approach in which nothing positive occurs for either of the staff nurses. This approach is detrimental to the morale of the unit. 4 - The charge nurse should attempt to resolve the conflict by negotiating for a win-win outcome for each party involved. A win-yield outcome discourages the staff nurses from attempting to resolve the conflict.

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? 1 - Administer a PRN sedative. 2 - Explain to the client the risk involved in leaving the hospital. 3 - Notify the client's next of kin. 4 - Assign an assistive personnel (AP) to provide one-to-one observation of the client.

2 - Explain to the client the risk involved in leaving the hospital. Rational 1- This action is considered a chemical restraint because a sedative would prevent the client from leaving the hospital 2 - The nurse has a legal responsibility to inform the client of the potential risks involved with leaving against medical advice. 3 - This action violates the client's right to confidentiality and autonomy. 4 - This action violates the client's right to autonomy and could be considered false imprisonment.

A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The nurse should recognize that the client's output is calculated and recored correctly when the AP perform which of the following actions? 1 - Includes 0.9% sodium chloride used to irrigate the catheter in the calculated output. 2 - Includes emesis and wound drainage in the total recorded output. 3 - Measures the urine using the markings on the drainage bag. 4 - Documents drainage in cubic centimeters (cc) on the intake and output form

2 - Includes emesis and wound drainage in the total recorded output. Rational 1 - The AP should deduct the amount of 0.9% sodium chloride used to irrigate the catheter from the total output. 2 - The nurse should recognize that the AP understands the concept of calculating a client's intake and output when the AP includes emesis and wound drainage into the calculation of the client's total output. 3 - To obtain an accurate measurement of the client's urine output, the AP should empty the urine into a graduated measuring container. 4 - The AP should document the client's intake and output using milliliters (mL) instead of cubic centimeters. The abbreviation "cc" is included on the Joint Commission's official "Do Not Use" list because it can be misinterpreted as units (U).

A nurse has just received change-of-shift report for a group of clients. Which of the following actions by the nurse demonstrates effective time management skills? 1 - Completes low-priority tasks first. 2 - Keeps a client to-do list for the day. 3- Charts client tasks at the end of the shift. 4 - Focuses on several client tasks at a time.

2 - Keeps a client to-do list for the day. Rational 1 - The nurse should complete client tasks that are the highest priority first, then move to lower priority tasks. 2 - The nurse should keep a client to-do list for the day, which allows the nurse to track the completion of the tasks as well as organize and manage time wisely. 3 - The nurse should chart as tasks are completed throughout the shift. Charting at the end of the day increases the risk of inaccuracy and error. 4 - The nurse should focus on one client at a time and complete one or two tasks during that time to demonstrate effective time management.

A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurse should identify that which of the following procedures requires an additional written informed consent? 1 - Obtaining an MRI 2 - Performing an amniocentesis 3 - Inserting an indwelling urinary catheter 4 - Placing an NG tube

2 - Performing an amniocentesis Rational 1 - Obtaining an MRI is covered by the general consent for treatment and does not require additional written informed consent. 2 - The nurse should ensure that the client has provided additional written informed consent prior to an invasive procedure, such as an amniocentesis. 3 - Insertion of an indwelling urinary catheter is covered by the general consent for treatment and does not require additional written informed consent. 4 - Placement of an NG tube is covered by the general consent for treatment and does not require additional written informed consent.

A nurse in a long-term care facility is preparing to demonstrate administration of a cleansing enema to a group of newly licensed nurses. Which of the following actions should the nurse plan to take during the demonstration? 1 - Administer 500 mL of solution. 2 - Place the client in a left side-lying position. 3- Lubricate the tip of the tube with petroleum jelly. 4 - Insert the tip of the tube 12.7 cm (5 in) into the client's rectum.

2 - Place the client in a left side-lying position. Rational 1 - For an adult client, the nurse should administer 750 to 1,000 mL of solution. 2 - The nurse should place the client on his left side, which allows the solution to flow by gravity into the sigmoid colon. 3 - The nurse should lubricate the tip of the tube with a water-based lubricant. 4 - For an adult client, the nurse should insert the tip of the tube 7.6 to 10 cm (3 to 4 in) into the rectum.

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? 1 - Provide the client with a cool environment. 2 - Provide the client with a reduced-calorie diet. 3 - Place the client on a fluid restriction. 4 - Place the client on strict bed rest.

2 - Provide the client with a reduced-calorie diet. Rational 1 - The nurse should provide a warm environment for the client who has hypothyroidism. 2 - The nurse should provide the client who has hypothyroidism with a reduced-calorie diet. Hypothyroidism causes the client's metabolism to decrease, which can result in weight gain. A reduced-calorie diet will help the client keep weight gain to a minimum and contribute to weight loss. 3 - The nurse should increase the client's fluid intake to at least 2 L per day. 4 - The nurse should encourage activity and ambulation, alternating with rest periods, for the client who has hypothyroidism.

A nurse is assisting in the planning of in-home care for a client following a right hip arthroplasty. Which of the following interventions is the nurse's priority. 1 - Provide the client with a list of follow-up appointments. 2 - Reinforce teaching about the client's use of a walker. 3 - Identify the client's support system. 4 - Discuss services that can assist the client with ADLs.

2 - Reinforce teaching about the client's use of a walker. Rational 1 - The nurse should ensure that the client is aware of follow-up appointments. However, this is not the nurse's priority. 2 - The greatest risk to this client is injury from a fall. Therefore, the priority intervention is to reinforce teaching with the client about safe ambulation with a walker. 3 - The nurse should identify the client's support system. However, this is not the nurse's priority. 4 - The nurse should ensure that the client receives assistance as needed with ADLs. However, this is not the nurse's priority.

A nurse is reinforcing teaching with a newly licensed nurse about ethical principles to consider during client care. Which of the following actions should the nurse include as an example of client advocacy? 1 - Selecting a home health care agency for a client in preparation for discharge 2 - Relaying a client's concerns about an upcoming procedure to the provider 3 - Asking a client who is verbally abusing staff to explain why she is angry 4 - Encouraging a client who wants to stop renal dialysis to continue with treatment

2 - Relaying a client's concerns about an upcoming procedure to the provider Rational 1 - Selecting a home health care agency for a client does not allow for client autonomy. The nurse should provide information for the client, but the client should make the choice. 2 - Acting as an intermediary between the client and other providers is an example of advocacy. 3 - Asking a "why" question is a nontherapeutic response that can exacerbate the client's defensive attitude. 4 - Attempting to change a client's mind or offering medical advice does not recognize the client's right to make decisions regarding health care.

A nurse is supervising an assistive personnel (AP) fax a client's morning laboratory results to the provider's office. Which of the following actions by the AP requires intervention by the nurse? 1 - Includes a cover sheet when faxing information 2 - Sends laboratory results from the past week 3 - Uses the fax machine at the nurses' station 4 - Dials with a programmed speed-dial

2 - Sends laboratory results from the past week Rational 1 - The AP should use a cover sheet to identify the intended recipient of the fax because a fax machine can serve a number of different users. 2 - The AP should only send the information requested by the provider. The amount of information sent by fax should not exceed what was requested or required for immediate clinical needs. 3 - The AP should use a fax machine in a secure area, such as the nurses' station, to ensure confidentiality of protected health information. 4 - The AP should use a programmed speed-dial key because it eliminates the chance of a dialing error and sending protected health information to the wrong location.

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-side 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? 1 - Physical therapy 2 - Speech therapy 3 - Cognitive therapy 4 - Occupational therapy

2 - Speech therapy Rational 1 - The nurse should refer the client for physical therapy to reduce the risk for injury due to left-sided weakness; however, another referral is the priority. 2 - When using the airway, breathing, circulation approach to client care, the priority referral is to the speech therapist. Difficulty swallowing indicates that this client is at risk for aspiration; therefore, a referral for speech therapy is the priority. 3 - The nurse should refer the client for cognitive therapy to reduce the risk for impaired cognitive function due to memory loss; however, another referral is the priority. 4 - The nurse should refer the client for occupational therapy to reduce the risk for impaired performance of ADLs due to left-sided weakness; however, another referral is the priority.

A nurse is assisting with the care of an older adult client who is recovering from a stroke and is experiencing difficulty swallowing and preforming ADL's. The client will be living with his adult son following discharge. The nurse should recognize that which of the following client referrals has the highest priority? 1 - Occupational therapy 2 - Speech therapy 3 - Social services 4 - Adult day care

2 - Speech therapy Rational 1 - This client could benefit from a referral for occupational therapy for assistance with ADLs. However, another referral is the priority. 2 - When using the safety vs. risk reduction approach to client care, the greatest risk to this client is aspiration and airway compromise from difficulty swallowing. Therefore, the priority referral is for speech therapy. A speech therapist specializes in evaluation, management, and improvement of swallowing difficulties. 3 - This client could benefit from a referral for social services to address psychosocial needs. However, another referral is the priority. 4 - This client could benefit from a referral for adult day care to occasionally assist the son in caring for the client following discharge. However, another referral is the priority.

A nurse is caring for a client who received a skin tear during a routine dressing change. After completing an incident report, which of the following actions should the nurse take? 1 - Document the completion of the incident report in the client's medical record. 2 - Submit the incident report to the nurse manager for review. 3 - Mail a copy of the incident report to the facility's attorney. 4 - Obtain the client's signature on the incident report.

2 - Submit the incident report to the nurse manager for review. Rational 1 - Incident reports are confidential health care facility documents and the nurse should avoid mentioning them in the client's medical record. 2 - The nurse should complete an incident report for unusual occurrences or variances in client care. The nurse manager should have the opportunity to review the information in order to begin the quality review process. 3 - The nurse should never photocopy an incident report or send it from the facility in the mail. This violates client confidentiality and increases the risk of the document being made public. 4 - The nurse should avoid obtaining the client's signature on the report, as this is not required.

A nurse assisting with disaster triage is examining a client who has a large open wound to the lower extremity. Which of the following actions should the nurse take? 1 - Assign the client a black tag. 2 - Tell the client she should receive treatment within 2 hr. 3- Inform the client she is in the emergent category. 4 - Apply an ice pack to the extremity for 30 min.

2 - Tell the client she should receive treatment within 2 hr. Rational 1 - When performing disaster triage, the nurse should plan to assign a black tag to clients who have minimal chance of survival or clients who are actively dying. A client who has an open fracture should receive a yellow tag. 2 - When performing disaster triage, the nurse should assign clients who have a large, open wound to the yellow, or urgent category. This is the second-priority client category, and clients who are in this category should receive treatment after the emergent group, but within 30 min to 2 hr. 3 - When performing disaster triage, the nurse should use the emergent category for clients who have an immediate threat to life, such as an airway impairment or significant, uncontrolled bleeding. 4 - When performing disaster triage, the nurse should not stop to provide treatment unless there is an immediate need. The nurse should recognize that ice and elevation are important interventions to reduce edema associated with a fracture and to lower the risk of complications. However, an ice pack should not be applied for more than 20 min.

A nurse is completing documentation of the computer at the nurse's station when an assistive personnel (AP) requests to use the computer to enter morning vital signs. Which of the following actions should the nurse take? 1 - Enter the AP's vital sign data for him. 2 - Allow the AP to use the computer while the nurse is still logged on. 3 - Ask the AP to find another computer. 4 - Tell the AP to come back at a later time.

3 - Ask the AP to find another computer. Rational 1 - The nurse should not chart for coworkers, such as entering the AP's vital sign data, because it implies that the nurse obtained the information and not the AP. 2 - The nurse should log off before allowing the AP to enter vital sign data. The computer terminal should never be left unattended by the person who is logged in. 3 - The nurse should ask the AP to find another computer that is not in use so that recording of information is completed in a timely manner. 4 - The AP's data is time sensitive and should be reported in a timely manner. The nurse should not ask the AP to delay documentation of client data.

A home health nurse is reinforcing teaching about the effects of carbon effects of carbon monoxide poisoning. Which of the following manifestations should the nurse include? 1 - Diarrhea 2 - Ringing in the ears 3 - Headaches 4 - Irritability

3 - Headaches Rational 1 - The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning. 2 - The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning. 3 - The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning. 4 - The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning.

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 indicated an understanding of the teaching? 1 - "My signature on the consent form indicates I informed the client he can't change his mind about the procedure." 2 - "By signing the consent form, I confirm that I was present when the provider explained the procedure to the client." 3 - "My signature on the consent form indicates the client gave consent for the procedure voluntarily." 4 - "By signing the consent form, I confirm that the client's family approves of the procedure."

3 - "My signature on the consent form indicates the client gave consent for the procedure voluntarily." Rational 1 - The nurse should inform the client that he has the right to change his mind about having the procedure, even after the procedure has begun. 2 - The nurse's responsibility is to confirm the client understands the provider's explanation. The nurse does not need to be present when the provider explains the procedure to the client. 3 - The nurse's signature on the consent form confirms that the client is competent to give consent, the client gave the consent voluntarily, and that the client's signature is authentic. 4 - The nurse should identify that it is not necessary for a family member to approve of the procedure. The nurse's signature confirms that the client is competent to give consent.

A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 2200. Which of the following recommendations should the committee make? 1 - Assign clients who are disoriented to rooms away from the nurses' station. 2 - Keep bedside tables with wheels away from the bed. 3 - Check on clients hourly. 4 - Raise four side rails while clients are in bed.

3 - Check on clients hourly. Rational 1 - Clients who are disoriented should be assigned to rooms nearest the nurses' station to allow more frequent observation by the nurse. 2 - The nurse should ensure bedside tables are placed near the bed to avoid clients reaching for needed items and falling out of bed. 3 - Evidence-based practice has shown that performing hourly rounds to provide assistance with toileting, pain, or client positioning is effective in reducing falls. 4 - If four side rails are in the raised position, the client can injure herself by attempting to climb over the side rail. Also, the provider must write a prescription to raise all four side rails while a client is in bed because it is considered a restraint.

A nurse is assisting with a presentation about nutrition for cancer prevention at a community center. Which of the following information should the nurse suggest including? 1 - Replace legumes with lean red meat. 2 - Eat three servings of fruits and vegetables daily. 3 - Consume fatty fish twice a week. 4 - Include different types of refined grains.

3 - Consume fatty fish twice a week. Rational 1 - The nurse should inform the group to limit red meat intake and avoid processed meats such as smoked, cured, or charred meats as part of cancer prevention. 2 - The nurse should inform the group to consume five or more servings of fruits and vegetables daily, or at least 2.5 cups, as part of cancer prevention. 3 - Consuming fatty fish at least twice weekly helps to increases omega-3 intake as part of cancer prevention. Eating white meats such as chicken or fish is preferred to consuming red meats. 4 - The nurse should inform the group to include various types of whole grains as part of cancer prevention. Refined or processed grains and sweets increase cancer risk.

A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. The client has a new diagnosis of diabetes and his partner is at the bedside. Which of the following actions should the nurse take? 1 - Ask the client's partner to translate written instructions for the client. 2 - After giving instructions, ask the client if he understands the teaching. 3 - Contact an interpreting service via telephone to assist with the instructions. 4 - Direct instructions about insulin administration to the client's partner.

3 - Contact an interpreting service via telephone to assist with the instructions. Rational 1 - The nurse should avoid using a family member to translate medical information and should provide the client with written instructions that are in his language. 2 - The nurse should implement teach-back technique, in which the client repeats the instructions back to the interpreter following the teaching. The interpreter should then communicate the client's understanding to the nurse. 3 - The nurse should contact an interpreting service to assist in communicating discharge information to the client if a medical interpreter is not available in person. The use of a medical interpreter ensures that medical information is accurately communicated to the client. 4 - With the client's consent, it is appropriate to include the partner when reinforcing teaching; however, the nurse should direct the instructions to the client.

A nurse enters the room of a client who is sleeping and observes spark coming for a frayed bed plug in the client's electrical outlet. Which of the following actions should the nurse take first? 1 - Unplug the client's bed. 2 - Pull the fire alarm closest to the area. 3 - Evacuate the client. 4 - Call maintenance for assistance.

3 - Evacuate the client. Rational 1 - The nurse should unplug any unsafe equipment to decrease the risk of a fire. However, another action is the priority. 2 - The nurse should activate the fire alarm closest to the problem area whenever smoke or fire is detected. However, another action is the priority. 3 - The greatest risk during a fire or a threat of fire is injury to the client or others; therefore, the first action is to evacuate the client from the room. This action is the first step of the Rescue, Alarm, Confine, and Extinguish (RACE) protocol. 4 - The nurse should notify maintenance of any unsafe equipment; however, another action is the priority.

A nurse is assisting an RN with developing a meal plan for a client who has neutropenia. Which of the following foods should then nurse recommend to include? 1 - Soft-boiled eggs 2 - Spinach salad 3 - Fried fish 4 - Celery stalks

3 - Fried fish Rational 1 - Soft-boiled eggs are not an appropriate food choice to include in the meal plan. Soft-boiled eggs are not fully cooked and place the client at risk for acquiring foodborne illnesses. 2 - Spinach salad is not an appropriate food choice to include in the meal plan. Raw spinach places the client at risk for acquiring foodborne illnesses. 3 - Fried fish is an appropriate food choice to include in the meal plan. Clients who have neutropenia should avoid undercooked meats to reduce the risk for acquiring foodborne illnesses. 4 - Celery stalks are not an appropriate food choice to include in the meal plan. Raw celery stalks place the client at risk for acquiring foodborne illnesses.

A nurse is reinforcing teaching with a newly licensed nurse about the administration of opioid pain medication. Which of the following instructions should the nurse include? 1 - Count the remaining narcotics after removing the client's medication from the locked dispenser. 2 - Place the unused portion of the client's medication in the sharps container at the nurses' station. 3 - Have a second nurse witness disposal of the unused portion of the client's medication. 4 - Report a discrepancy in the narcotic count immediately after administering the medication to the client.

3 - Have a second nurse witness disposal of the unused portion of the client's medication. Rational 1 - The nurse should count the narcotics before removing the pain medication from the dispenser to determine the correct count of the medication. 2 - The nurse should dispose of the unused narcotic according to the facility's policy. The nurse should never discard the medication in a sharps container. 3 - The nurse should ask a second nurse to witness the disposal of any unused portion of the client's medication. The witnessing nurse should also sign the medication record as a witness to the disposal of the unused medication. 4 - The nurse should report any medication discrepancy before administering the narcotic medication to the client, rather than after.

A nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse plan to take? 1 - Include the client's vital sign record in the discharge instructions. 2 - Begin discharge planning 24 hr prior to the client's scheduled discharge date. 3 - Include community resource phone numbers with the client's discharge instructions. 4 - Obtain a 3-month supply of the client's prescribed medications.

3 - Include community resource phone numbers with the client's discharge instructions. Rational 1 - The client's vital sign record is not necessary to include in the discharge instructions. The nurse should include the most recent vital signs in the change-of-shift report, or if the client is transferred to another unit. 2 - The nurse should begin discharge planning upon admission to ensure a timely, effective discharge. 3 - The nurse should provide the client with contact information for community resources, as well as the provider, to enhance care and provide easy access in the event of complications or questions. 4 - The nurse can recommend a referral to social services if the client expresses concerns about obtaining prescribed medications. The facility does not maintain the resources to provide each client with a 3-month supply of medication upon discharge.

A nurse is caring for an adolescent client 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? 1- Contact the facility chaplain to speak with the family. 2 - Reinforce teaching with the parents about why the blood transfusion is necessary. 3 - Inform the charge nurse and recommend that social services be contacted. 4 - Ask the client if she will accept the blood transfusion.

3 - Inform the charge nurse and recommend that social services be contacted. Rational 1 - The nurse should avoid contacting the facility chaplain to speak with the family because this might offend the parents. 2 - The nurse should avoid educating the parents about why the blood transfusion is necessary after they have not consented due to religious beliefs. 3 - The nurse has an obligation to act as an advocate for the client. The nurse should inform the charge nurse of the parents' decision and recommend that social services is contacted to further advocate for the client. 4 - The nurse should avoid asking the client if she will accept the blood transfusion because the client is a minor and cannot provide consent for a transfusion.

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. 1 - One nurse is assigned to complete care for one client. 2 - A group of nurses work together to care for a group of clients. 3 - Nurses are assigned specific tasks to perform for each of the clients. 4 - Assignments are made based on client location within the unit.

3 - Nurses are assigned specific tasks to perform for each of the clients. Rational 1 - Nurses use a total client care model when assigning a nurse complete care for one client. 2 - Nurses use a team nursing model when assigning a team to care for a group of clients. 3 - Nurses use a functional nursing model when assigning specific tasks to staff. This approach places the focus on the task to be performed. 4 - Nurses use a team nursing model when assigning a team to care for a group of clients based on client location within the unit.

A nurse is assigned to care who is in isolation. Which of the following actions should the nurse take to manage time effectively while caring for this client? 1 - Assign an assistive personnel (AP) to apply a medicated ointment during perineal care. 2 - Store several sets of extra bed linens in the client's room. 3 - Organize care into groups that can be performed at one time. 4 - Schedule time at the end of the shift to document all client care

3 - Organize care into groups that can be performed at one time Rational 1 - This action is outside the range of function of the AP. The nurse should apply medicated ointment. 2 - The nurse should not store extra linens in the client's room to prevent contamination of supplies. 3 - The nurse should implement this strategy to streamline the workflow by providing less fragmented care and reducing time spent traveling from area to area. 4 - The nurse should document information as soon as possible after providing client care. Delays can result in inaccurate and incomplete documentation.

A charge nurse is planning a discussion concerning scope of practice with newly licensed nurses. Which of the following tasks should the charge nurse identify as within the PN's scope of practice? Select all 1 - Plan nursing care for clients who have complicated diagnoses. 2 - Delegate the care of a client to an RN. 3 - Participate in health promotion counseling for a client. 4 - Evaluate a client's response to nursing interventions. 5- Assist in the development of unit policies affecting client care.

3 - Participate in health promotion counseling for a client. 4 - Evaluate a client's response to nursing interventions. 5- Assist in the development of unit policies affecting client care. Rational 1 - Plan nursing care for clients who have complicated diagnoses is incorrect. It is within the PN's scope of practice to contribute to the plan of care for clients who have stable, rather than complicated conditions. 2 - Delegate the care of a client to an RN is incorrect. It is within the PN's scope of practice to assign the care of a client to an assistive personnel or another PN, not an RN. 3 - Participate in health promotion counseling for a client is correct. It is within the PN's scope of practice to participate in counseling for client health promotion. 4 - Evaluate a client's response to nursing interventions is correct. It is within the PN's scope of practice to participate in the evaluation of a client's responses to nursing interventions. 5 - Assist in the development of unit policies affecting client care is correct. It is within the PN's scope of practice to assist in the development of policies and procedures.

A nurse is assisting with the development of an in-service about the process of evidence-based practice. Which of the following actions should the nurse include as the first step of this process? 1 - Locate research articles in current scientific journals. 2 - Critically examine the evidence to determine if it is reliable. 3 - Question a current clinical practice that does not seem effective. 4 - Make changes to policies that reflect new evidence-based guidelines.

3 - Question a current clinical practice that does not seem effective. Rational 1 - The nurse should include that it is important to locate research articles in current scientific journals to further investigate a problem-focused trend in current clinical practice. However, there is another action the nurse should take first when following the steps of evidence-based practice. 2 - The nurse should include that it is important to critically examine the evidence to determine if it is reliable and appropriate for use in the current problem. However, there is another action the nurse should take first when following the steps of evidence-based practice. 3 - According to the steps of evidence-based practice, the nurse should include to first question a current clinical practice that doesn't seem effective to identify a problem-focused trend to investigate further. 4 - The nurse should include that it is necessary to make changes to policies that reflect new, evidence-based guidelines to ensure implementation of the needed changes. However, there is another action the nurse should take first when following the steps of evidence-based practice.

A nurse is collecting data from a client and notices smoke coming from an electrical outlet. Which of the following actions should the nurse take first? 1 - Activate the nearest fire alarm. 2 - Spray a fire extinguisher in an arc at the outlet. 3 - Take the client out of the room. 4 - Close the doors and windows to the client's room.

3 - Take the client out of the room Rational 1 - The nurse should activate the fire alarm to obtain help and to notify others of the danger. However, there is another action the nurse should take first. 2 - If conditions are safe, the nurse should attempt to extinguish the fire. However, there is another action the nurse should take first. 3 - The greatest risk to this client is injury from smoke or fire. Therefore, the first action is to take the client out of the room and away from danger. This action follows the Rescue, Activate, Confine, Extinguish (RACE) protocol. 4 - The nurse should attempt to contain the fire. However, there is another action the nurse should take first.

A nurse is contributing to the plan of care for a group of clients. Which of the following scenarios demonstrate effective use of time management techniques? 1 - The nurse finishes collecting physical assessment data on a client who is resting quietly before checking on a client who reports nausea. 2 - The nurse leaves change-of-shift report early to begin client care activities. 3 - The nurse groups activities for a surgical client based on the client's pain medication schedule. 4 -The nurse waits to evaluate the client's care until the end of each shift.

3 - The nurse groups activities for a surgical client based on the client's pain medication schedule. Rational 1 - The nurse should deliver care based on priorities she has established. However, when interruptions to the routine occur, such as a client who reports nausea, the nurse needs to reprioritize based on client needs. 2 - The nurse should obtain all information from the change-of-shift report before making a list of priorities and activities to accomplish during the shift. Insufficient information can lead to inadequate care. 3- The nurse should anticipate when the client will need pain medication and schedule care activities at a time when the client is most comfortable and able to move, which will assist the client to meet goals and allow the nurse to plan care more effectively. 4 - The nurse should evaluate the client's response to care throughout the shift, which allows the nurse to change plans as needed, plan actions at appropriate times, and document outcomes in a timely manner.

A nurse is collecting data from a client following abdominal surgery. The nurse should recognize which of the following client findings is the priority to report to the provider? 1 - Reports incisional pain during ambulation 2 - Inadvertent removal of an indwelling urinary catheter 3- Surgical dressing saturated with bloody drainage 4 - Swelling at the IV catheter insertion site

3- Surgical dressing saturated with bloody drainage Rational 1 - This report requires further data collection to identify nursing interventions to address the incisional pain while ambulating. However, another finding is the priority to report. 2 - This finding requires further data collection to determine the client's condition and address the removal and possible reinsertion of the indwelling urinary catheter. However, another finding is the priority to report. 3 - When using the airway, breathing, and circulation approach to client care, the nurse determines that the priority finding to report to the provider is the surgical dressing saturated with bloody drainage. This finding indicates the client is possibly experiencing postoperative hemorrhage, which can lead to hypovolemia and shock. 4 - This finding requires further data collection to determine the cause of the swelling at the IV insertion site. However, another finding is the priority to report.

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? 1 - "You will be fine. I've seen many new mothers cope with this situation." 2 - "Have you considered taking a community parenting class?" 3 - "Once you get past the postpartum period, you'll feel better about handling these challenges." 4 - "How do you feel about discussing your concerns with a social worker?"

4 - "How do you feel about discussing your concerns with a social worker?" Rational 1 - This is a nontherapeutic response because it is dismissive of the client's concerns. 2 - This is a nontherapeutic response because it does not address the client's concerns. There is no indication that the client needs parenting education. 3 - This is a nontherapeutic response because it provides false reassurance. 4 - This is a therapeutic response by the nurse because it addresses the client's concerns and ultimately provides the client with resources to help meet her specific needs. The social worker can connect the client with supportive community resources.

A nurse is verifying informed consent with a client who is scheduled to have a total open abdominal hysterectomy with bilateral salpingo-oophorectomy for the treatment of uterine cancer. The nurse should notify the provider for which of the following client statements? 1 - "My parents are sad they won't have any more grandchildren." 2 - "I don't look forward to having menopause symptoms." 3 - "My recovery will be slower because of the abdominal incision." 4 - "I wish I knew if there was another way to treat this other than surgery."

4 - "I wish I knew if there was another way to treat this other than surgery." Rational 1 - The nurse should identify that this statement indicates the client understands informed consent, because a client who has a total hysterectomy will no longer be able to become pregnant. 2 - The nurse should identify that this statement indicates the client understands informed consent, because once a client has her ovaries removed, manifestations of menopause, such as hot flashes and vaginal dryness, can begin. 3 - The nurse should identify that this statement indicates the client understands informed consent, because a total open abdominal hysterectomy will require an incision, as opposed to a vaginal hysterectomy, which requires no skin incision. 4 - The nurse should contact the provider to clarify the procedure and other options with the client. It is the provider's responsibility to inform the client of any other treatment options.

A nurse in a provider's office is reinforcing discharge teaching with an adult client who has a new prescription for ear drops for an inner ear infection. Which of the following instructions should the nurse include? 1 - "Hold the drops 4 cm (1.6 in) above the ear canal to instill the medication." 2 - "Wait 1 minute before repositioning after instilling the ear drops." 3 - "Pull the tip of your ear backward before instilling the ear drops." 4 - "Lie on your side when preparing to instill the ear drops."

4 - "Lie on your side when preparing to instill the ear drops." Rational 1 - The nurse should instruct the client to hold the dropper 1 cm (0.4 in) above the ear canal to ensure that the medication reaches the inner ear. 2 - The nurse should instruct the client to remain in a side-lying position for 2 to 3 min after instilling the ear drops. 3 - The nurse should instruct the client to pull the auricle of the ear upward and outward to instill the ear drops. 4 - The nurse should instruct the client to lie on her side with the affected ear upward to instill the ear drops.

A nurse is discussing the meaning of utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of this ethical theory? 1 - "Utilitarianism identifies the needs of the individual as priority." 2 - "Utilitarianism represents my duty to provide compassionate care to all clients." 3 - "Utilitarianism focuses on human dignity as its fundamental principle." 4 - "Utilitarianism provides the greatest good for the greatest number of people."

4 - "Utilitarianism provides the greatest good for the greatest number of people." Rational 1 - The utilitarian ethical theory places the needs of the group over that of the individual. 2 - The deontological ethical theory represents the nurse's duty to all clients. 3 - The deontological ethical theory focuses on human dignity as an underlying principle. 4 - The nurse indicates an understanding of the ethical theory of utilitarianism by stating that the basis for this theory provides the greatest good for the greatest number of people.

A nurse in a long-term care facility is caring for an older adult client who has heart failure and is refusing to take a new medication. Which of the following response should the nurse make? 1 - "You need to take this medication to feel better." 2 - "Many clients take this medication for your condition." 3 - "I will come back later to give you the medication." 4 - "You have the right to refuse the medication."

4 - "You have the right to refuse the medication." Rational 1 - The nurse should support the client's decision to refuse the medication and provide an explanation that can encourage the client to take the medication. 2 - The nurse should support the client's decision to refuse the medication and provide an explanation that can encourage the client to take the medication. 3 - The nurse should support the client's decision to refuse the medication and provide an explanation that can encourage the client to take the medication. 4 - The nurse should recognize the client's right to refuse the medication to support the client's autonomy. The nurse should document this in the client's medical record and notify the provider.

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? 1 - A client who has a penetrating head wound and has been assigned a black tag 2 - A client who has a compound fracture to the left arm and has been assigned a yellow tag 3 - A client who has multiple abrasions and bruising to the trunk and has been assigned a white tag 4 - A client who has paradoxical respirations and has been assigned a red tag

4 - A client who has paradoxical respirations and has been assigned a red tag Rational 1 - The nurse should prepare to transport the client who has a penetrating head wound; however, the nurse should transport another client first. A client who has a penetrating head wound has minimal chance of survival, even with intervention. 2 - The nurse should prepare to transport the client who has a compound fracture; however, the nurse should transfer another client first. A client who has a compound fracture does not have an immediate threat to life and can be treated at a later time. 3 - The nurse should prepare to transport the client who has multiple abrasions and bruising; however, the nurse should transfer another client first. A client who has multiple abrasions and bruising does not have an immediate risk to life and can be treated at a later time. 4 - When using the airway, breathing, circulation approach to client care, the nurse should transport the client who has paradoxical respirations first. A client who has paradoxical respirations requires immediate intervention for survival, due to airway compromise.

A nurse is assisting with the development of a presentation for newly licensed nurses regarding client confidentiality. Which of the following actions should the nurse include as an example of a breach of client confidentiality? 1 - Signing in and out of the computer terminal after each data entry using a facility-specific universal passcode 2 - Refusing to share a personal passcode with a new provider who needs to access data about an urgent client 3 - Printing each assigned client's current medication list and shredding the documents at the end of the shift 4 - Accessing client medical records from other units to compare outcomes with currently assigned clients

4 - Accessing client medical records from other units to compare outcomes with currently assigned clients Rational 1 - The nurse should use a personal password to log in to a facility computer terminal and always log out when finished entering data. 2 - The nurse should never share a personal password with anyone, including other members of the health care team. 3 - The nurse should shred confidential information or place information containing client identifiable information into the locked bin labeled "shred" at the end of each shift, such as the current medication list for each assigned client. 4 - The nurse should only access the medical records of currently assigned clients. Accessing client records from other units is a breach of client confidentiality and can result in disciplinary and legal action.

A nurse is planning to delegate care for a group of clients following change-of-shift report. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? 1 - Setting up the sterile field for a client who is scheduled for a lumbar puncture 2 - Obtaining a wound culture from a client 3 - Reinforcing teaching with a client on how to perform coughing and deep-breathing exercises 4 - Applying bilateral sequential compression devices to a client's legs

4 - Applying bilateral sequential compression devices to a client's legs Rational 1 - The nurse should not delegate setting up a sterile field to an AP because this skill is not within the range of function for an AP. Preparing a sterile field requires specialized knowledge and nursing judgment to prevent contamination of the field and ensure client safety. 2 - The nurse should not delegate obtaining a wound culture to an AP because this skill is not within the range of function for an AP. Obtaining a wound culture requires specialized knowledge and nursing judgment to prevent contamination of the culture. 3 - The nurse should not delegate reinforcing teaching about coughing and deep-breathing exercises to an AP because providing education is not within the range of function for an AP. 4 - The nurse should delegate applying sequential compression devices to an AP because this skill is used routinely in client care, creates minimal safety risk for the client, and is within the range of function for an AP.

A nurse in a long-term care facility is caring for a resident who is refusing his prescribed medications. Which of the following actions should the nurse take first? 1 - Notify the provider that the client is refusing his medications. 2 - Document the client's refusal in the medication administration record. 3 - Explain the benefits of the medications to the client. 4 - Identify the client's concerns about taking the medications.

4 - Identify the client's concerns about taking the medications. Rational 1 - Notifying the provider that the client is refusing his medications is important to determine any necessary changes in the client's plan of care. However, there is another action the nurse should take first. 2 - Documenting the client's refusal in the medication administration record is a required action by the nurse. It is important to verify why the client is not meeting treatment goals and the documentation might be required in the event of future legal proceedings. However, there is another action the nurse should take first. 3 - Explaining the benefits of the medications to the client can improve the client's understanding of treatment goals and the provider's purpose for prescribing the medications. However, there is another action the nurse should take first. 4 - The first action the nurse should take when using the nursing process is to collect data from the client. By identifying the client's concerns and reasons for refusing the medications, the nurse can determine which actions to take next to prevent worsening of the client's condition.

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? 1 - Report the situation directly to the facility's risk manager. 2 - Determine if both of the APs are directly involved in the client's care. 3 - Place a completed incident report in the client's medical record. 4 - Inform the APs that the conversation violates the client's confidentiality.

4 - Inform the APs that the conversation violates the client's confidentiality. Rational 1 - The nurse should follow the facility's chain of command for reporting a breach of confidentiality and should not report this directly to the hospital risk manager. After intervening to stop the conversation, the nurse should report the incident to the charge nurse. 2 - Regardless of whether both of the APs are directly involved in the client's care, they are violating the client's confidentiality by having this discussion in a public place. 3 - Incident reports are used by a facility to document and further investigate variances in the standard of care. These reports are only for the facility's use and the nurse should not place the report in the client's record, nor mention in the record that a report was completed. 4 - The nurse should intervene immediately to stop the conversation and protect the client by informing the APs that the conversation violates the client's confidentiality.

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? 1 - Clinical expertise of facility nurses 2 - Review of medical records 3- Facility performance indicators 4 - Peer-reviewed nursing journals

4 - Peer-reviewed nursing journals Rational 1 - The nurse should include information from clinical experts because they have first-hand knowledge of interventions that help prevent falls. However, it is not the primary guideline the nurse should use. 2 - The nurse should include client data so that trends can be identified. However, it is not the primary guideline the nurse should use. 3 - The nurse should include facility performance indicators because this demonstrates the fall rate of clients, which can be compared to nationwide numbers. However, it is not the primary guideline the nurse should use. 4 - The nurse should collect data from peer-reviewed journals when contributing to the development of a new policy. This is the primary guideline the nurse should use because it is current, accurate, and research-based.

A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for the client at home? 1 - Endotracheal tube 2 - Petroleum gauze 3 - Sterile povidone iodine 4 - Portable suction

4 - Portable suction Rational 1 - A client who has a tracheostomy will not require an endotracheal tube. If the client has a tracheostomy with a disposable cannula, the nurse should ensure that additional cannulas are available. 2 - The nurse should ensure that the client has dry 4x4 gauze dressings for tracheostomy care, rather than petroleum gauze. The nurse should use a commercially prepared split-gauze tracheostomy dressing around the stoma. 3 - The nurse should ensure sterile 0.9% sodium chloride irrigation solution is available for tracheostomy care, rather than sterile povidone iodine. 4 - The nurse should ensure that a portable suction device and other suctioning equipment is available in the home to clear respiratory secretions.

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 indicated that the charge nurse should intervene? 1 - Returns unopened supplies from a client's room to the storage room 2 - Obtains assistance when lifting an object that weighs 18.1 kg (40 lb) 3 - Double-bags a biohazard bag that is contaminated on the outside 4 - Stands with feet close together while transferring a client from the bed to a chair

4 - Stands with feet close together while transferring a client from the bed to a chair Rational 1 - The AP should return unopened supplies from a client's room to the storage room to provide cost-effective care. 2 - The AP should obtain assistance from another staff member or use proper equipment to prevent injury when lifting more than 15.9 kg (35 lb). 3 - The AP should double-bag a biohazard bag that is contaminated on the outside to prevent the transmission of infection. 4 - The AP should stand with feet wide apart while transferring a client from the bed to a chair to increase stability and prevent self-injury.

A nurse arrives for her shift and is assigned more clients that she feels 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? 1 - Request to float to another unit. 2 - Refuse the assignment and leave the unit. 3 - File an incident report with the risk manager. 4 - Submit a written complaint to the nursing supervisor

4 - Submit a written complaint to the nursing supervisor Rational 1 - The nurse who requests to float to another unit fails to address the issue of safety for client care and adds to the unit's shortage of nursing staff. 2 - The nurse who leaves the unit when there is a shortage of nursing staff fails to address the issue of safety for client care and can legally be considered committing client abandonment. 3 - The nurse should file an incident report when there is an occurrence that deviates from the standard of care. This report does not address the current situation regarding the client care assignment. 4 - The nurse should submit a written complaint to the nursing supervisor detailing her concern if she must accept an assignment for more clients than she feels is safe. This written complaint ensures that the facility is aware of the issue and indicates that the nurse made an attempt to address the situation.

A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events events should the nurse document as a variance? 1 - The nurse on the prior shift administered the client's twice-daily antibiotic 1 hr after it was due. 2 - The nurse hears two assistive personnel discussing the client in a public elevator. 3 - The client reports she does not have an advance directive. 4 - The client has a circular area of nonblanchable redness on her left heel.

4 - The client has a circular area of nonblanchable redness on her left heel. Rational 1 - The nurse can administer routine medications that are prescribed twice-daily up to 1 hr before or after it is scheduled. However, this is not a variance to a critical pathway. 2 - Two assistive personnel discussing the client in a public location is a legal violation of the client's privacy. The nurse should report this event following the chain of command. However, this is not a variance to a critical pathway. 3 - The nurse should document in the medical record that the client does not have an advance directive, and provide the client with information about completing an advance directive. However, this is not a variance to a critical pathway. 4 - A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on her left heel as a variance because this indicates the initial stage of a pressure ulcer and is not an expected outcome.

A nurse is participating on a committee that is revising the facility's policies and procedures for infection control. Which of the following statements should the nurse recommend to include in the facility's infection control manual? 1- Double-bag linens prior to removing them from the client's room. 2 - Place sterile objects within 1.3 cm (0.5 in) inside the edge of a sterile field. 3 - Apply a surgical mask to a client on contact isolation prior to transporting to radiology for an x-ray. 4 - Use a 1:10 bleach solution to clean blood spills.

4 - Use a 1:10 bleach solution to clean blood spills. Rational 1 - Soiled linens should be placed in a single, impermeable bag before leaving the client's room. Double-bagging is not used unless the outside of the bag becomes contaminated. 2 - All sterile objects should be placed at least 2.5 cm (1 in) inside the edge of a sterile field. 3 - A surgical mask is used when the client who is on droplet precautions is transported. 4 - The nurse should recommend using a 1:10 bleach solution to decontaminate blood spills.

A nurse realizes she has administered the wrong medication to a client. Which of the following actions should the nurse take first? 1 - Notify the charge nurse. 2 - Check the client's medication administration record (MAR). 3 - Complete an incident report. 4- Monitor the client's vital signs.

4- Monitor the client's vital signs. Rational 1 - The nurse should notify the charge nurse if a medication error occurs. However, another action is the priority. 2 - The nurse should check the client's MAR to determine which client medications could cause interactions. However, another action is the priority. 3 - The nurse should complete an incident report if a medication error occurs. However, another action is the priority. 4 - The greatest risk to this client is injury from receiving the wrong medication. Therefore, the priority action is to collect data from the client. By checking the client's vital signs, the nurse can determine if the client is experiencing an adverse reaction and whether immediate intervention is needed.