ATI Leadership Practice Questions

A nurse is teaching a group of newly licensed nurses about violations of pt rights. Which of the following examples of a violation of pt rights should the nurse include in the teaching? A. a pt who is confused & recovering from ABD trauma has mitten restraints placed to prevent disruption of an ABD wound B. a pt who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sec C. a health care proxy releases the med records of a pt to a long-term care facility for a placement eval D. the parents of a 16 yr old has gunshot wounds decide to limit their child's visitors to family members only

B. a pt who has schizophrenia is places in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex Rationales.. Seclusion is a restraint that should be used when a pt is demonstrating violent / self-destructive behavior that jeopardizes the safety of self / others. This pt does not meet the criteria for seclusion A. this pt is at risk of cauing self injury by disrupting the ABD wound. The nurse should apply mitten restraints, which are less restrictive than wrist restraints C. the pt's health care proxy has the authority to consent to the release of med records D. a 16 ur old is a minor, the pt's parents have the right to make this decision for the pt

Due to staffing shortages, a nurse manager floats a med surg nurse to the pediatric unit. This nurse has limited experience w/ children. Which of the following actions should the nurse manager take? A. provide constant supervision for the med surg nurse B. have the med surg nurse provide relief for unit nurses during break & lunch times C. assign a unit nurse to act as a resource for the med surg nurse D. delegate assistive personnel tasks to the med surg nurse

C. assign a unit nurse to act as a resource for the med surg nurse Rationales.. Assigning a nurse who usually works on the peds unit to assist the med surg nurse will provide consistent support

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first? A. discuss w/ the charge nurses their responsibility in implementing the change B. post a sign-up sheet for in-service training sessions about the new system C. ask informal leaders to participate in the early implementation process D. collect the staff members' input about planning & implementing the change

D. collect the staff members' input about planning & implementing the change Rationales.. The nurse manager should first assess the situation by collecting the staff members' input & collaborating about implementing the change smoothly & efficiently

A nurse is creating a plan of care for a pt who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. backed pork chop B. cheeseburger C. ham & cheese omelet D. grilled salmon

D. grilled salmon Rationales.. The nurse should recommend grilled salmon for a pt who observes Kosher dietary laws. Grilled salmon is a fish w/ fins & scales, which can be consumed. Seafood w/ shells, such as lobster / crab is prohibited

A nurse is preparing to give a change of shift report to the oncoming nurse. Which of the following pieces of info should the nurse include? A. routine care procedures for the pt B. biographical info C. assumptions regarding relationships among the pt's family members D. objective measurements about the pt's condition

D. objective measurements about the pt's condition Rationales.. The nurse should include objective observations & measurements about the pt's conditions in the report

A nurse is tracking the outcomes of pts on the unit who have received postop pain management. This activity demonstrates which of the following competencies of QSEN initiative? A. safety B. informatics C. patient centered care D. quality improvement

D. quality improvement Rationales.. This QSEN competency involves using data to track outcomes w/ the goal of devising processes to improve pt's outcomes A. this QSEN competency involves using national safety guidelines & goals to provide safe pt care B. this QSEN competency involves navigating pts electronic health records & using technology effectively to manage pt care C. this QSEN competency involves determining pts needs, preferences, & values & providing care that addresses these parameters

A nurse is participating in an ethics committee meeting about a pt who has a hx of alcohol use disorder & needs a liver transplant. Which of the following actions should the committee take first? A. collect info r/t the issue B consider the possible choices of action C. make a decision regarding transplant recommendation D. justify the recommendation for or against a transplant

A. collect info r/t the issue Rationales.. According to EBP, the committee should take the first step in ethical decision-making by ID th ethical issue & problem. This step includes asking questions to define the issue & the complexities of the situation B. the 2nd step in ethical decision-making involves ID & analyzing all of the available alternatives for action, even if the actions seem unlikely C. the 3rd step in ethical decision-making involves selecting one of the alternative actions to follow. The committee should apply ethical principles to make the best decision possible D. this is the final step in ethical decision making. The committee should specify reasons for the action selected & be able to present the ethical basis behind the decisions made

A nurse is planning care for a pt who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend? A. spiritual advisor B. social worker C. physical therapist D. occupational therapist

B. social worker Rationales.. The nurse shoulf recommend a referral to a social worker when a pt will require additional services, such as home health care, oxygen therapy, hospice care, or wound care A. the nurse should recommend a referral to a spiritual advisor for a pt who requests spiritual counsel / guidance C. the nurse should recommend a referral to a physical therapist for a pt who requires assistance w/ mobility & range of motion activities of the upper and lower extremities D. the nurse should recommend a referral to an occupational therapist for a pt who has difficulty performing ADLs

A nurse is reviewing lab results for a pt who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? A. Hgb 12 g/dL B. WBC 15,000/mm^3 C. fasting blood glucose 80 mg/dL D. serum creatinine 0.4 mg/dL

D. serum creatinine 0.5 mg/dL rational.. this value is below the expected ref range for a pt who is pregnant. The nurse should report this value to the provider. The other values are w/in the expected ref range for a pt who is pregnant

A nurse is caring for a male pt who is scheduled for a procedure. The pt's son asks the nurse what med is being given to the pt. Which of the following responses should the nurse provide? A. "I am sorry, but you'll need to ask your father for that info B. "your father was given lorazepam to treat anxiety" C. "you will need to ask the charge nurse for that info" D. "don't worry, we will give your father all pertinent info before discharge"

A. I am sorry, but you'll need to ask your father for that info Rationales... The nurse must keep the pt's personal health info confidential. It is up to the pt to share confidential info w/ his son B. telling the pt's son about his med w/out the pt's permission is a breach of confidentiality C. the charge nurse would also need permission from the pt to give info to the son D. This statement does not answer the son's question U& dismisses his concerns

A nurse manager believes that a nurse is taking breaks that are too frequent & lengthy. Which assertive statement should the charge nurse use to initiate a discussion of the issue? A. I understand you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior B. you are taking more breaks during each shift than hospital policy allows. You will need to take only the number of breaks specified & ensure you are back on time C. you have been taking too many breaks during each shift & do not return on time after your break. I will have to make a formal not about this issue that will be reflected on your next performance appraisal D. why do you take so many breaks? Are you aware there is a policy that designated how many breaks you can take

A. I understand you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior

A nurse in a mental health clinic is interviewing a pt who has a hx of substance use disorder. The pt reports his experiences from a previous voluntary hospitalization. Which of the following reported experiences by the pt constitutes assault? A. I was threatened w/ a shot when I refused to take an oral med that I knew would make me groggy B. I was held down against my will & admin a shot C. I was told I had to stay in the facility despite my request to leave D. I was exposed as a substance abuser to other pts in a group session

A. I was threatened w/ a shot when I refused to take an oral med that I knew would make me groggy Rationales.. Threatening to medicate pts against their wishes is assault. The tort of assault occurs when a person puts another in fear of nonconsensual contact B. performing any procedure on a pt w/out informed consent is battery, not assault. The tort of battery occurs when there is nonconsensual contact w/ one's person C. not allowing pts to leave a health care facility despite their wishes is false imprisonment, not assault. Mental health pts who admit themselves voluntarily to a psychiatric facility retain that right to sign themselves out of the facility D. sharing info w/ others not directly involved in the pt's care is a violation of the pt's confidentiality, not assault

A nurse in an ED is caring for 4 pts. Which of the following findings requires the nurse to act as a mandatory reporter? A. a child who was left unsupervised for several hours at home and is being treated for a fractured leg B. a pt who was admitted for pneumonia and reports having no heat or running eater at home C. a pt who has depression & a self-inflicted wrist laceration D. a public official who is admitted w/ alcohol withdrawal & delirium tremens

A. a child who was left unsupervised for several hours at home and is being treated for a fractured leg Rationales.. This child exhibits findings of neglect & endangerment. The nurse is a mandatory reports for any pt situation in which children / older adult pts are being abused / neglected B. this pt would benefit from a referral to social services for assistance w/ living conditions. Mandatory reporting of this situation to legal authorities is not indicated C. none of the info given indicates that this pt is a danger to others. This pt will likely be placed on suicide precautions, but disclosure to a legal authority is not indicated D. sharing this info outside the care team for this pt is a violation of HIPAA regulations. Disclosure to a legal authority is not indicated

A nurse is planning care for several pts. Which of the following pts should the nurse refer to a case manager? A. a pt who has neurological deficits following a stroke B. a married female pt who has delivered a full-term newborn C. a pt who is postop following a cholecystectomy D. a child who has a fracture of the dominant arm

A. a pt who has neurological deficits following a stroke Rationales... The nurse should refer this pt to the cast manager for care. A pt who had a stroke will likely require long-term tx. A pt who has ongoing needs for care / rehab should receive care that is directed by a case manager due to the complexity & cost of the pt's needs B. if no complications / social concerns exist, the delivery of a full-term newborn does not require case management C. as long as no complications occur, this procedure does not require a case management approach D. a child who has a fractured arm does not require a case management approach unless there is evidence that some other pathology precipitated the fracture

A nurse is preparing to provide discharge teaching to an older adult pt. Which of the following teaching considerations should the nurse include? A. allow frequent rest periods during teaching B. use colored paper w/ a glossy finish C. present the info at a tenth-grade reading level D. use 12 point font size

A. allow frequent rest periods during teaching Rationales.. The nurse should allow frequent periods of rest since an older adult pt processes info more slowly B. the nurse should use white / buff-colored paper w/ a matte finish to avoid glare C. the nurse should present the info at a sixth to eighth grade reading level D. the nurse should use at least a 14 point font size for an older adult pt when developing written materials

A nurse is caring for a group of pt's on a med surg unit. Which of the following tasks should the nurse delegate to an AP? SATA A. collecting a stool specimen B. providing instructions about using a spirometer C. measuring oral intake D. providing postmortem care E. changing a sterile dressing

A. collecting a stool specimen C. measuring oral intake D. providing postmortem care Rationales.. These tasks do not require assessment, analysis, or teaching & are w/in the range of function for an AP

A nurse manager is evaluating the time-management strategies of a newly licensed nurse on the ped unit. Which of the following actions taken by the nurse are effective time-management strategies? A. completing one task before beginning another task B. documenting pt care at the end of the shift C. taking time to plan care at the beginning of the shift D. completing more time-consuming tasks at the end of the shift E. mentally visualizing a procedure prior to gathering equipment

A. completing one task before beginning another task C. taking time to plan care at the beginning of the shift E. mentally visualizing a procedure prior to gathering equipment Rationales.. Completing one task before beginning another task, planning care at the beginning of the shift, and mentally visualizing a procedure prior to gathering equipment are effective time management strategies for the newly licensed nurse. Daily planning is important for managing and prioritizing tasks B. documenting pt care at the end of shift is not an effective time management strategy. The newly licensed nurse should document care as soon as possible after an intervention is completed to facilitate accuracy and thorough documentation D. completing more time-consuming tasks at the end of the shift is not an effective time management strategy. The newly licensed nurse should complete more difficult / strenuous tasks earlier in the day when energy levels are higher. This strategy also helps avoid procrastination

A nurse is planning care for a group of pts. Which of the following actions should the nurse plan to take? A. delegate the admin of an intermittent tube feeding to a LPN B. assign an AP to monitor a pt's dressing for evidence of bleeding C. ask an AP to explain to a pt how to empty a urinary leg bag D. delegate the admin of a unit of packed RBCs to a pt to an LPN

A. delegate the admin of an intermittent tube feeding to a LPN Rationales.. Admin a tube feeding is w/in the scope of practice for an LPN B. this task requires assessment skills that are not w/in the scope of practice of an AP C. an LPN is responsible for pt teaching / reinforcement of teaching D. although an LPN can assist an RN w/ packed RBC admin by monitoring pt's receiving blood products, an LPN's scope of practice does not involve admin packed RBCs

A nurse manager is planning staff development activities for the unit's new UAP. Which of the following activities should the nurse manager perform first? A. determine the learning needs of the UAPs B. admin a skills pretest to the new UAPs C. provide the new UAP's w/ a performance checklist D. ask the UAPs about any weaknesses they may have

A. determine the learning needs of the UAPs Rationales.. The nurse should apply the nurseing process priority-setting framework to plan pt care & prioritize nursing actions. Assessing or collecting additional data will provide the nurse w/ the knowledge to make an appropriate decision

A charge nurse in an ED is making assignments for an AP during a shift w/ unexpected staff absences. Which of the following assignments should the charge give to a float AP from the med surg unit? A. escorting pts from the ED to other areas of the facility for tests B. sitting at the reception desk answering telephones & directing pts C. restocking the exam rooms after each pt is discharged D. shadowing an AP who is regularly assigned to the ED

A. escorting pts from the ED to other areas of the facility for tests Rationales... Pts in the ED often require transport to other departments. Typically, transporting stable pts is a task that may be delegated to an AP, & escorting pts is likely a normal part of the AP's regular routine

A community health nurse is performing pt triage while participating in a disaster drill. The nurse should recommend that which of the following pt injuries received tx first? A. hemothorax B. open humeral fracture C. multiple deep abrasions on the arms & face D. superficial partial-thickness burns on both legs

A. hemothorax Rationales.. A hemothorax is life-threatening, but w/ chest-tube insertion & stabilization, the pt is likely to survive

A nurse is transporting a pt to the surgical suite for a procedure. The pt tells the nurse he no longer wants to have the surgery. Which of the following responses should the nurse make? A. let me call your surgeon while you tell me about your concerns B. you should talk to your family before you make this decision C. I'll ask your surgeon to speak to you as soon as you are in the surgical suite D. everything will be fine. The operation will be over soon, and you will be glad you had it done

A. let me call your surgeon while you tell me about your concerns Rationales.. The pt has the right to refuse tx. Speaking w/ the nurse & the provider about concerns / questions could relieve anxieties & allow the pt to continue w/ the procedure. Consent may be withdrawn after being given. It is the nurse's responsibility to notify the surgeon if the pt verbalizes a desire to stop / delay a medical procedure / treatment

A nurse receives the morning change-of-shift report & delegates several tasks to an AP on the team. Which of the following tasks should the nurse instruct the AP to perform first? A. obtain the morning capillary blood glucose tests B. bathe a pt scheduled for physical therapy at 0900 C. distribute the breakfast trays D. fill pitchers w/ fresh water & ice

A. obtain the morning capillary blood glucose tests Rationales.. The most urgent task the AP should complete is obtaining the morning cap BG test

A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse ID as a sentinel event? A. paralysis of a pt's lower extremities occurred following epidural anesthesia B. a pt fall during ambulation did not result in pt injury C. a pt's family member complained that a nurse was culturally insensitive D. surgery to the wrong site was stopped prior to a procedure

A. paralysis of a pt's lower extremities occurred following epidural anesthesia Rationales.. An incident resulting in permanent harm, such as paralysis or death, is a sentinel event. Sentinel events are a high priority & indicate the need for an immediate investigation B. the committee should review this incident & policies to reduce the risk & occurrence of falls in the facility; a pt fall that does not result in injury is not a sentinel event C. the committee should review the incident & policies to promote culturally competent care; this type of adverse event is not ID as a sentinel event D. the nurse should ID this type of incident as a near-miss, which happens when an error is caught & prevented before it occurs

A nurse is providing teaching to a pt about organ donation. Which of the following statements by the pt indicates an understanding of the teaching? A. people age 18 & over have the right to decide to make an organ donation B. I have to make organ donation a provision in my will C. once I decide to donate, I cannot change that decision D. a family member has to serve as a witness for me to be an organ donor

A. people age 18 & over have the right to decide to make an organ donation Rationales... Under the Uniform Anatomical Gift Act, individuals must be at least 18 yrs or older to make an anatomical gift B. under the UAGA, organ donation can be a provision in a will or done by signing a form designated by the state (on a driver's license). It must be in writing w/ a signature C. under the UAGA an individual can revoke consent for organ donation by either destroying the card / revoking the gift orally in the presence of two witnesses D. under the UAGA, nurses may serve as witnesses for individuals who wish to donate organs

A nurse is caring for a pt who received a sedative-hypnotic med at bedtime. The pt gets out of bed & falls, sustaining a laceration that requires suturing. Which of the following statements should be included as part of the nurse's documentation in the pt's chart? A. pt found sitting on floor w/ 3 cm laceration about left eyebrow. Oriented to name only. Provider notified B. pt found sitting on floor w/ blood running down face. Side rails had not been raised by assistive personnel when pt was placed in bed C. pt fell due to confusion caused by sleeping med D. pt got out of bed and fell, despite being told to call for assistance when ambulating

A. pt found sitting on floor w/ 3 cm laceration above left eyebrow. Oriented to name only. Provider notified Rationales.. This statement is appropriate to include in the documentation. It presents objective facts & assessments r/t this event. The nurse should also include vital signs, further assessments, the name of the provider notified, treatments/procedures that were does per the provider's prescription, and the pt's response B. this statement is not appropriate to include in the documentation bc it includes a nondescript comment that is open to interpretation. Blame is also placed on the AP for not putting up the side rails C. this statement is not appropriate to include in the documentation bc it draws a conclusion about why the pt fell. Although sedative-hypnotic meds can cause confusion, it is inappropriate to assume that the med caused the fall D. this statement is not appropriate to include in the documentation bc it places blame on the pt

A charge nurse is planning a department in-service training session about radioactive implants for a group of staff nurses. Which of the following points should the charge nurse include in the presentation? SATA A. pts should be places in a private room B. throw away an implant that has fallen out in the pt's trash can C. staff members should wear a dosimeter badge when caring for the pt D. pts should be on bed rest E. children over the age of yrs can visit if they are accompanied by an adult

A. pt's should be placed in a private room C. staff members should wear a dosimeter badge when caring for the pt D. pt's should be on bed rest Rationales.. Pt/s should be placed in a private room to avoid exposing other pt's to radiation from the implant. The nurse should follow the principles of time, distance, and shielding when working w/ a pt who is recieving internal radiation therapy. Health care providers should wear a dosimeter badge. This badge measures & records a staff member's amount of exposure to radiation. Pt's who have a radioactive implant should remain on bed rest while the implant is in place to prevent dislodgement. B. the nurse should pick up a radioactive implant that has fallen out w/ forceps & place it in a lead container E. children under the age of 16 yrs & women who are pregnant are prohibited from visiting a pt who has a radioactive implant

A school nurse is assessing a child who has multiple bruises on his trunk & extremities. The child reports falling out of a tree 2 days ago. The nurse's assessment findings show patterns of bruising that are not typically sustained during a fall from a tree. Which of the following actions should the nurse take? A. report the findings to local police & social service agencies B. report the finding to the school district superintendent C. call the parents of the child & further assess the causative event D. reassess the child on a weekly basis for injuries

A. report the findings to local police & social service agencies Rationales.. Health care providers are required to report suspected child abuse. The nurse's primary concern is the safety of the child. Procedures for reporting differ in various locations, but procedures involve notification of police & social services personnel who can investigate the situation B. the nurse should report suspicions of abuse to the authorities & should not share private info w/ others w/in the school system C. the physical assessment findings support a suspicion of abuse. The nurse should report this suspicion to the authorities for further investigation. The nurse's legal responsibility is the safety of the child D. if abuse is occurring in the child's home, waiting to intervene could put the child at risk for further abuse / serious injury. The nurse is obligated to report the suspicion of abuse immediately

A nurse is walking w/ a pt who falls after the facility-issued walker loses a wheel. Which of the following actions should the nurse take regarding the completed incident report? A. submit the variance report to the risk manager B. place the variance report in the pt's chart C. document the completion of the incident report in the pt's med record D. make a copy of the variance report for the provider

A. submit the variance report to the risk manager Rationales.. Incident report are confidential documents used by the institution to imporve pt care. Filing an incident report does not supersede the need for documenting the assessment in the pt's med record & notifying the provider. Once completed, the variance form should be submitted to the institution's risk manager B. incident reports are confidential documents used to improve pt care. The nurse should not place the report in the pt's chart C. the nurse should not document the completion of an incident report in the pt's med record D. the nurse should not make a photocopy of the incident report, as this would allow attorneys to subpoena a copy of the report for potential use in litigation

A nurse suspects that a coworker is under the influence of alcohol. Which of the following behaviors in the workplace are consistent w/ substance use disorder? SATA A. taking extended lunch periods & breaks B. calling in sick frequently on Mondays / Fridays C. expressing frustration w/ work assignments D. demonstrating decreased concern about personal appearance & grooming E. using excessive amounts of cologne / mouthwash

A. taking extended lunch periods & breaks B. calling in sick frequently on Mondays/Fridays D. demonstrating decreased concern about personal appearance & grooming E. using excessive amounts of cologne / mouthwash Rationales.. Extended lunch periods & breaks may indicate that the individual is ingesting alcohol in a remote location. Calling in sick frequently on Mondays or Fridays may imply that the individual is binge drinking on weekends and is too ill to come to work. Decreased concern about personal appearance and grooming and excessive use of cologne or mouthwash are signs of substance use disorder. D. frustration w/ assignments is a common workplace behavior but does not necessarily indicate substance use disorder

A nurse is delegating a pt care task to an AP. Which of the following directions should the nurse give the AP? A. this pt needs to ambulate using a walker 3x daily B. please record strict intake & output for this pt C. this pt needs to have blood glucose monitoring before each meal D. please obtain vital sings from all the pts to whom you are assigned today

A. this pt needs to ambulate using a walker three times today Rationales.. This direction includes the type of task to be done, the frequency w/ which the tasks is to be performed, the duration of the task, & the info about the mechanics of ambulating the pt B. strict intake & output does not provide enough direction for the AP. it does not explain how this expectation differs from "regular" intake & output & whether the values need to be reported to the RN C. this direction does not provide a specific time / details for monitoring the pt's BGL. It does not clarify how the values should be documented & whether they should be reported to the NR D. this direction does not ID the frequency at which this task is to be performed on each pt / the parameters for reporting findings

A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a nonpunitive approach, which of the following actions should the nurse manager take? A. verbally remind the employee about the facility's employment standards B. recommend that the employee review the facility's policy regarding absences C. Inform the employee in writing about the facilities employment policy D. ask the employee for a written action plan after discussing the reasons for these absences

A. verbally remind the employee about the facility's employment standards Rationales... Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior B. Recommending that the employee reviews the policy does not ensure that the employee will read & fully understand the employment standards C. written admonishment is the second step in the disciplinary process for this type of infraction. If the employee fails to make a positive behavioral change after being verbally reminded by the manager about the facility's employment standards, the nurse manager should inform the employee writing D. this is an example of performance-deficiency coaching, which the nurse manager should use to correct unacceptable behaviors over time

A home health nurse is caring for a pt who asks about the purpose of a living will. Which of the following statements should the nurse include in the teaching? A. "It est. who will make health care decisions for the pt if the pt is not about to do so" B. "it allows the pt to express personal wishes regarding health care decisions" C. "It serves as an informed consent form for any procedure prescribed by a provider" D." It is only valid when a pt is lucid & able to make informed decisions independently"

B. It allows the pt to express personal wishes regarding health care decisions Rationales... A living will allows the pt to specify what aspects of care & tx are to be accepted / refused in the event that the pt can no longer communicate those decisions A. this described a health care proxy document, which frequently accompanies a living will but is not considered a part of it C. A living will does not serve the same function as informed consent. Prior to any procedure, consent must always be obtained form the pt, a family member, or a designated health care proxy D. A living will is not valid / necessary when a pt is able to make informed health care decisions independently

A nurse is speaking w/ the family member of a pt who has early Alzheimer's disease. The family member would like to keep the pt living at home, but the pt requires assistance whole the family member is away at work. Which of the following services should the nurse include in the discussion? A. hospice care B. adult day care C. assisted-living facility D. long-term care facility

B. adult day care Rationales... Adult day care personnel can proivde constant assistance w/ ADLs while the family member is at work; the pt can live at home during the night & evening hours A. hospice care is only appropriate for a tp who has a terminal illness & a life expectancy of <6 months C. pts who live in an assisted living facility need to be able to live independently & require minimal assistance. Pts can receive assistance w/ med & are offered one prepared meal a day if needed. An assisted living facility is not an option at this time since the family member wishes to keep the pt at home D. a long-term care facility is not an option at this time since the family member wishes to keep the pt at home

A nurse enters the room of an older adult pt & finds him attempting to crawl over the side rail of his bed. Which of the following actions should the nurse take? A. tell the pt that he will be put in restraints if he attempts to get out of bed again B. ask an AP to sit w/ the pt C. remind the pt to stay in bed D. restrain the pt immediately to prevent self-harm

B. ask an assistive personnel to sit w/ the pt Rationales.. This pt is at risk of falling. Having an AP sit w/ the pt protects him from harm. The nurse can contact the provider to discuss care options for this pt (restraints / placing an audible alarm) A. the nurse in this situation is threatening the pt w/ restraints if a change in behavior does not occur, which is a form of assault C. this pt is at risk of falling, & this action will not promote the pt's immediate safety. Nurses are negligent for failing to make provisions for pt safety when the situation requires D. the nurse should apply restraints only when necessary to protect the pt from harm & after all other alternative measures are exhausted

A nurse is delegating a task to an AP. The AP is to transfer a pt who has a below-the-knee amputation from a bed to a wheelchair. The AP has never transferred a pt w/ an amputation before. Which of the following actions should the nurse take? A. provide the AP w/ a manual on how the transfer should be done B. assist the AP after he has practiced the transfer C. transfer the pt while the AP observes D. ask another AP to transfer the pt

B. assist the AP after he has practiced the transfer Rationales.. The safest way for the nurse to determine if the AP has the knowledge & skill to transfer the pt who has an amputation is by having the AP practice & demonstrate the task. By assisting the AP w/ the first transfer, the nurse helps ensure that delegated care is safely provided A. providing a manual on the procedure alone will not adequately ensure the safety of the pt during the transfer C. although this strategy may be used to demonstrate to the AP how to transfer an amputee, it does not allow hands-on practice for the AP D. while this action will accomplish the task of transferring the pt, it does not address the AP's need to learn how to transfer a pt who has an amputation

A nurse is discussing w/ a newly licensed nurse about how to obtain informed consent from a pt who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. beneficence B. autonomy C. paternalism D. justice

B. autonomy rationales.. informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, & freedom of choice A. beneficence is based on the principle that actions should be taken w/ the intent to do good. It is associated w/ nonmaleficence, which is the requirement that health care providers do no harm to their pts. Although this is an important ethical principle in nursing, it is not the bases for informed consent C. paternalism is based on the assumption that one person can assume responsibility for making the decisions of another person. This principle limits freedom of choice D. justice is based on the principle that everyone should be treated similarly & fairly. This is an important ethical principle but is not the basis for informed consent

A nurse is caring for a pt who is undergoing a repair of an abdominal aortic aneurysm. After the surgery & immediate post op recovery, the nurse should expect which of the following team members to coordinate the pt's ongoing & specific needs for care? A. charge nurse B. case manager C. vascular surgeon D. home health care nurse

B. case manager Rationales.. The case manager's role is to plan & coordinate resources & sevices to help meet the pt's needs over the continuum of care A. the charge nurse's responsibilities include focusing on the day-to-day operations of the nursing unit, not on the specific needs of individual pts C. the surgeon's responsibilities focus on intraoperative care as well as immediate post op needs, post op care, and management of complications D. the home health care nursing staff's responsibilities include meeting the pt's care needs, not coordinating them

After entering a pt's room, a nurse notices the pt has fallen on the bathroom floor. Which of the following actions should the nurse perform first? A. obtain support from another nurse B. check the pt for injuries C. file an incident report D. notify the pt's provider

B. check the pt for injuries Rationales.. The greatest risk to this pt is an injury from falling on the floor; the first action the nurse should take is to look for skin tears, cuts, or bruises & to obtain the pt's vital signs A. the nurse should obtain support from another nurse before filing the incident report if additional info / a witness is needed; the nurse should take another action first C. the nurse should file an incident report to record the pt's fall & to prevent future falls; the nurse should take another action first D. the nurse should notify the pt's provider about the fall & communicate whether the pt was injured & needed tx; the nurse should take another action first

A nurse enters a pt's room & finds the pt lying on the floor next to the bed. Which of the following actions should the nurse take first? A. determine the cause of the incident B. check the pt for injuries C. call for assistance to get the pt back into bed D. complete an incident report

B. check the pt for injuries Rationales... The first action the nurse should take when using the nursing process is to assess the pt. The nurse should determine whether the pt has sustained any injuries from the fall & implement interventions to ensure the pt's safety & wellbeing A. the nurse should determine the cause of the incident to prevent further risks; however, there is another action the nurse should take first C. the nurse should call for assistance to place the pt back into beck, the pt should not be moved until an assessment by the nurse has been completed D. the nurse should complete an incident report w/ factual info regarding the incident, there is another action the nurse take first

A nurse is providing discharge teaching about wound care to a pt who has a leg wound. Which of the following pieces of info should the nurse include in the teaching? SATA A. use cotton balls to clean the infected areas B. cleanse the wound w/ tap water C. dry the leg wound after cleaning it D. microwave the cleaning solution before applying to the wound E. discard soiled bandages in a moisture-proof bag

B. cleanse the wound w/ tap water E. discard soiled bandages in a moisture-proof bag Rationales.. Tap water / 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages & gloves should be places in double-bagged, moisture-proof bags & not in the regular trash. This prevents the spread of contamination to other family members w/in the household A. cotton balls should not be used bc the fibers can get caught in the wound & cause an infection; gauze squares / nonwoven swabs should be used to clean the wound C. drying the leg wound after cleaning should be avoided. The wound should be open to the air to allow the wound to retain moisture & promote healing D. the nurse should warm the cleaning solution to the body temp if possible, using a microwave to warm the solution can make it too hot

A nurse manager est. staff nurse committees to address unit issues, institutes an open-door policy for speaking about concerns, and supports professional staff development. Which of the following leadership styles is this nurse manager displaying? A. laissez-faire B. democratic C. autocratic D. transactional

B. democratic Rationales.. The democratic manager encourages the staff to participate in decision-making, communicates effectively, offers constructive criticism, and believes the best of people A. laissez-faire manager provides little structure or direction for a group C. an autocratic management style is characterized by behaviors such as making all decisions w/out staff input, focusing on task completion, & limiting access to communication w/ the manager D. a transactional leader focuses on getting work done & the task to be completed

A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies to help reduce costs. Which of the following types of leadership is the nurse manager using? A. autocratic B. democratic C. laissez-faire D. moral

B. democratic Rationales.. This is an example of democratic leadership. A democratic leader guides staff toward on objective & shares responsibility w/ the staff. This is the ideal type of leadership in this situation because a great amount of creativity can occur, and many strategies can be developed A. and autocratic leader makes decisions independently & notifies staff of the decisions made. An autocratic manger maintains a high degree of control & allows little freedom of staff members C. a laissez-faire leader exerts little or no leadership & control. This manager is providing staff w/ direction & leadership D. moral leadership involves honesty & fairness under any circumstances

A nurse is assisting a provider w/ an amniotomy on a pt who is in labor. Which of the following is the priority nursing assessment following the procedure? A. color of amniotic fluid B. fetal heart rate C. uterine contraction pattern D. odor of amniotic fluid

B. fetal heart rate rationales.. The greatest risk to this pt is an injury from umbilical cord prolapse following artificial rupture of the membranes; the nurse should monitor the fetal heart rate for bradycardia, which can indicate an increased risk of umbilical cord prolapse A. the nurse should assess the color of the amniotic fluid for blood / meconium stool to check for fetal distress C. the nurse should assess the pt's uterine contraction pattern to determine if oxytocin should be given to stimulate contractions D. the nurse should assess the odor of the amniotic fluid to check for infection

A charge nurse on a med surg unit is assigning pt care to the upcoming shift. Which of the following tasks should the nurse delegate to an AP? SATA A. performing colostomy care B. measuring a pt's intake & output C. interpreting a pt's lab values following surgery D. providing postmortem care to a pt E. checking nasogastric tube patency

B. measuring a pt's intake & output D. providing postmortem care to a pt Rationales.. Measuring the intake & output of a pt & providing postmortem care are w/in the range of function for an AP A. performing colostomy care involves data collection, which is outside the range of function for an AP this tasks should be delegated to a LPN C. Interpreting a pt's lab values following surgery involves data collection & is outside the range of function for an AP this tasks should be delegated to an LPN E. checking nasogastric tube patency should be delegated to an LPN not an AP

A nurse is admin meds to a pt who is recovering from a stroke & has right-sided paralysis. The nurse places the pt's meds on the left side of the mouth & admins pills one at a time. Which of the following ethical principles in the nurse displaying? A. autonomy B. nonmaleficence C. fidelity D. justice

B. nonmaleficence Rationales.. Nonmaleficence is the duty to do no harm & protect pt's from harm by eliminating threats. These actions taken by the nurse are important for the safety of the pt by preventing aspiration A. autonomy is the right to self-determination, independence, and freedom of choice C. fidelity is the obligation to be faithful to commitments make to self & others D. justice is the obligation to be fair & to treat people in an equal manner

A nurse is making a pt's bed & finds a capsule of med in the sheets. Which of the following actions by the nurse is consistent w/ safe nursing practice? SATA A. admin the med to the pt B. notify the provider C. complete a variance report D. document the finding in the pt's electronic med record E. place the med back in the med drawer

B. notify the provider C. complete a variance report Rationales.. B. notifying the provider is correct. The nurse should notify the provider of the finding as a part of the variance reporting process C. completing a variance report is correct. The nurse should complete an incident / variance report regarding the occurrence A. admin the med to the pt is incorrect. The nurse should not admin the med to the pt bc the nurse does not know which does of the med the pt missed. Admin the capsule now could result in an overdoes if the pt has recently taken the same med D. documenting the finding in the pt's electronic med record is incorrect. The nurse should not document the finding in the pt's electronic med record. The nurse should ID the info in the pt's medical record is subjective to attorney review should the pt decide, for any reason, to file suit against the facility / the healthcare staff. Instead, the nurse should follow facility policy & report the incident to the nurse manager and risk management through the nurse of a variance report, the nurse should avoid documenting in the med record that a variance report was filed bc this can also allow for the variance report to be subpoenaed should the pt decide to file suit E. placing the med back in the med drawer is incorrect. The nurse should ID that meds that are no longer packaged are considered contaminated & should be discarded

A charge nurse is planning an in-service training session about pt advocacy w/ a group of staff nurses. Which of the following situations should the nurse include as an example of pt advocacy? SATA A. discussing tx options w/ a pt who was dx w/ pancreatic cancer B. notify the provider when a pt has questions about eh procedure C. helping a pt make a lsit of questions to ask the provider D. clarifying the dosage of a med prescribed for a pt who has impaired liver function E. carrying out the end of life wishes outlined in the living will of an older adult pt who has end stage renal disease

B. notifying the provider when a pt has questions about the procedure C. helping a pt make a list of questions to ask the provider D. clarifying the dosage of a med prescribed for a pt who has impaired liver function E. carrying out the end of life wishes outlined in the living will of an older adult who has end stage renal disease Rationales.. As a pt advocate, the nurse should make sure pts have all thier questions answered & possess the info needed to make an informed decision. Clarifying the dosage of a med prescribed for a pt who impaired liver function can prevent med toxicity & demonstrates pt advocacy. Carrying out the end-of-life wishes of a pt who has end-stage renal disease demonstrates pt advocacy

A nurse is preparing to attend a care plan conference for a pt who has severe burns. Which of the following criteria should the nurse ID as part of an effective conference? A. the planning process for the conference is centered on the nursing staff B. other health care professionals are in attendance at the conference C. controversial opinions regarding the plan of care are not tolerated during the conference D. the conference is focused on a discussion of the pt's health care issues w/ minimal attention to resolving them

B. other health care professionals are in attendance at the conference Rationales.. The nurse should ID that an effective conference should consist of other health care professionals who contribute to the plan of care for goal setting & seek to est. positive pt outcomes. The members of the conference consists of the nursing team who should invite other health professionals (ex physical therapists, dieticians, & occupational therapists) to contribute to the plan of care A. the planning process for the conference should address goals r/t the pt's care plan & positive pt outcomes C. during any pt care plan conference, there will be differences of opinion. It is important to encourage a climate of respect & a nonjudgmental attitude so that all attendees can work toward remaining open-minded about other attendees' contributions. This can lead to more productive sharing & positive pt outcomes D. the purpose of the conference is to develop resolutions for the numerous pt care problems that require an inter-professional team to set goals & measurable positive outcomes

A nurse is preparing a pt for a lumbar puncture. The pt has signed the consent form but tells them nurse that she does not remember what the doctor will do during the procedure. Which of the following actions should the nurse take? A. page the provider stat to come & explain the procedure to the pt B. remind the pt that the doctor will insert a needle to get a sample of fluid from her spine C. explain how the assistant will position the pt for the procedure D. tell the pt that someone will explain the procedure when it is time to begin

B. remind the pt that the doctor will insert a needle to get a sample of fluid from her spine Rationales... A signed consent form indicates that the provider informed the pt about the procedure & that at the time the pt understood what to expect. If the pt states she does not remember what to expect, the nurse should clarify any details the provider previously gave the pt. If the pt expresses a further lack of understanding or states that the provider did not inform her, the nurse should either notify the charge nurse or call the provider directly A. the signed consent form indicates that the provider explained the procedure to the pt previously. the nurse should have confirmed this when witnessing the consent C. although the nurse should provide this info, this reponse does not clarify what the provider will do once the pt is in position & directs the focus away from what the pt wants to know D. this response is nontherapeutic, rejects the pt's concern, & fails to ID the need for the nurse to take further action

A nurse is part of a facility committee charged w/ developing & implementing new documents forms. The nurse should recognize which of the following factors as a potential restraining force for implementing this change? A. approval of the forms by the nursing admin B. staff members' resistance to learning new forms of documentation C. recognition of the facility unit that completes the implementation first D. development of high-quality monitoring tools for compliance w/ new documentation

B. staff members' resistance to learning new forms of documentation Rationales.. Restraining forces impede change. Staff members' resistance to learning a new documentation system can be a restraining force. As a result, the committee must develop a plan for implementation that recognizes this threat. A. approval of the new documentation forms occurs as part of the process of development, and the committee should complete this step before implementation C. recognition serves as a driving force for implementation rather than a restraining force D. the development of tools to monitor compliance w/ new documentation forms is part of the evaluation phase, not the implementation phase

A charge nurse is providing teaching to a new staff nurse about the management of a team consisting of a LPN & an AP. Which of the following pieces of info should the charge nurse include in the teaching? A. the LPN can delegate the task of teaching a pt about foot care to the AP B. the LPN should be familiar w/ the task she plans to delegate C. the person who accepts the delegated task also assumes accountability for the task D. the LPN can delegate an initial assessment of a pt to the LPN

B. the LPN should be familiar w/ the task she plans to delegate Rationales.. The nurse should be familiar w/ the task she plans to delegate so she can define the task as well as the expectation of its completed status, monitor the performance of the task, and provide feedback regarding the performance A. the nurse should not delegate the task of teaching a pt about foot care, as this task is not w/in the scope of practice for an AP C. while the person who accepts the delegated task assumes the responsibility for the task, accountability for any delegated task remains w/ the nurse who delegated it D. It is the responsibility of the RN to complete the initial assessment of a pt admitted to a nursing unit

A nurse on a med surg unit is caring for a group of pts. For which of the following situations should the nurse complete a variance report? A. a clarification of a med dosage prescribed by a provider B. the discovery that a preoperative pt has received & eaten breakfast C. the ID of a safety concern w/ a piece of equipment D. a dispute w/ a coworker about pt assignments

B. the discovery that a preop pt has received & eaten breakfast Rationales.. This situation represents a variation from the standard of care. A change in the pt's plan of care is necessary bc the surgical procedure will need to be delayed. The nurse should complete a variance report for this situation A. it is the nurse's responsibility to clarify prescription that might pose a safety issue for the pt. The situation does not require a variance report C. if the nurse ID a safety concern w/ a piece of equipment, it should be removed from use, and the nurse should follow the facility's procedure for placing a work order for repair. This situation does not require a variance report D. this staff problem should be resolved between the coworkers w/ possible mediation by the nurse manager. This situation does not require a variance report

A charge nurse is performing a quality-assurance audit on the documentation of several pts' charts. Which of the following documentation items should the charge nurse ID as a correct entry in the pt's medical record? A. the pt appeared angry when family members were visiting B. the pt ambulated for 10 min three times during the shift C. the pt seemed to be upset about the dx D. an incident report was completed when the pt fell at 1000

B. the pt ambulated for 10 min three times during the shift Rationales.. The charge nurse should ID that this documentation item reflects objective data about the pt's actions A. the documentation item is an interpretation of the pt's feelings. The documentation should use pt quotes about how the pt is feeling whne documenting subjective data rather than relying on the sures's perception of the pt's emotions C. the documentation item is an interpretation of the pt's feelings. The documentation should use pt quotes about how the pt is feeling when documenting subjective data rather than relying on the nurse's perception of the pt's emotions D. documentation about the completion of an incident report should never be noted in the pt's medical records. The nurse can document info about the events surrounding the incident in the med record (ex. the fall & resulting pt outcomes)

A group of nurses on a telemetry unit informs a nurse manager of a need to update the cardiac monitoring system to improve arrhythmia detection. Which of the following responses should the nurse manager make? A. this purchase will require the completion of a variance analysis B. this purchase will need to be addressed in the capital budget plan for the unit C. this purchase will result in a reduction in the operating budget D. this purchase can be reimbursed my Medicare funds, as pts who use Medicare will benefit from the equipment

B. this purchase will need to be addressed in the capital budget plan for the unit Rationales.. The capital budget involves planning for spending r/t equipment & major purchases that have a long life of use A. the anticipated purchase of new equipment does not require a variance analysis. Variance analysis is a process that differentiates planned budget results from actual results C. an operating budget is separate from the budget for large expenditures for equipment / other major purchases. This type of budget reflects expenses that change in response to the volume of service (supplies, electricity) D. Medicare funds do not reimburse institutions of equipment purchases, even though pts who are receiving Medicare use the equipment

A nurse is preparing to teach the health care team about the concepts of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include? A. a critical pathway is a plan of care specific to the nursing interventions necessary for pt care B. a critical pathway is a tool that legally binds the health care facility to provide services as outlined C. a critical pathway is a multidisciplinary tool that guides pt care & bases outcomes on an externally imposed timeline D. a critical pathway is a plan that may be the same for several similar dx

C. a critical pathway is a multidisciplinary tool that guides pt care & bases outcomes an externally imposed timeline Rationales.. A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired pt outcomes & an appropriate length of stay for the particular dx

A charge nurse on a med surg unit is making assignments for the oncoming shift. Which of the following pts should the charge nurse assign to a LPN? A. a pt who requires an updated plan of care following a dx of cancer B. a pt who is postop following a total hip replacement & requires discharge teaching C. a pt who has a prescription for irrigation of an indwelling urinary catheter D. a pt who has just arrived from PACU & requires a head-to-toe assessment

C. a pt who has a prescription for irrigation of an indwelling urinary catheter Rationales... It is w/in the scope of practice of an LPN to irrigate an indwelling urinary catheter when prescribed by a provider A. an RN should develop & update a pt's plan of care B. an RN should provide discharge teaching to a pt D. an RN should perform an assessment of a pt

A nurse is caring for a group of pt's on a med surg unit. Which of the following pts should the nurse attend to first? A. a pt who is receiving metoclopramide & reports diarrhea B. a pt who is receiving tamsulosin & reports feeling dizzy C. a pt who is receiving cephalexin & reports dyspnea D. a pt who is receiving erythromycin & reports epigastric pain

C. a pt who is receiving cephalexin & reports dyspnea Rationales.. The greatest risk to this pt is an injury from dyspnea due to an allergic reaction from the antibiotic. The pt is at risk of anaphylactic shock w/ a compromised airway. The nurse should first discontinue cephalexin & notify the provider immediately. Emergency equipment should be placed in the pt's room in case the pt goes into anaphylactic shock

A nurse is caring for a pt w/ stage 4 ovarian cancer who has decided to stop tx & enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the pt in her decision? A. responsibility B. accountability C. advocacy D. confidentiality

C. advocacy Rationales.. By following the ethical principle of advocacy, the nurse supports the pt in the decisions she makes about her own health care

A nurse is performing a safety audit on all equipment used on the unit. Which of the following items should the nurse ID as a safety hazard? A. an electrical cord that is taped to the floor B. a protective cover that is placed over an unused outlet C. an electrical cord that is frayed toward the plug D. an electrical plug that has 3 prongs

C. an electrical cord that is frayed toward the plug Rationales... the nurse should ID that an electrical cord that is frayed toward the plug is damaged & should not be used. Using an electrical cord that is damaged can increase the pt's risk of acquiring an electrical shock A. an electrical cord taped to the floor prevents others from tripping over the cord / damaging it B. a protective cover places over an unused outlet prevents young children from playing w/ the outlet D. an electrical plug w/ 3 prongs is a grounded piece of equipment, which provides a path of low resistance to stray electric currents. This is the only type of electrical equipment that should be used

A group of providers is participating in a cardiopulmonary resuscitation effort for a pt who is in cardiac arrest. Which of the following types of leadership is required for this group to function efficiently? A. transformational B. participative C. autocratic D. laissez-faire

C. autocratic Rationales... Autocratic leadership is most effective in an emergency situation. An autocratic leader will direct & issues commands that are necessary for successful cardiopulmonary resuscitation A. transformational leadership is not appropriate for an emergency situation gives group members responsibilities that will enhance their professional development. In cardiopulmonary resuscitation, one person must organize the group's actions & guide the resuscitation efforts B. participative leadership, also called "democratic leadership", it not appropriate for an emergency situation. A participative leader serves as a resource person & facilitator & is non-directive. In cardiopulmonary resuscitation, one person must organize the group's actions. D. Laissez-faire leadership is not appropriate for an emergency situation. A laissez-faire leader demonstrates a non-directive approach. In cardiopulmonary resuscitation, one person must organize the group's actions & guide the resuscitation efforts

A nurse is reviewing the med admin record for a pt & notes that the nurse from the previous shift gave double the dose of antihypertensive med prescribed to the pt. Which of the following actions should the nurse take first? A. file an incident report w/ factual info about the error B. report the incident to the nursing supervisor C. check the pt's condition D. notify the pt's provider about the incident

C. check the pt's condition Rationales.. The greatest risk to this pt is an injury from low BP due to a double does of antihypertensive med. The first action the nurse should take is to check the pt's condition & obtain the pt's vital signs, including BP

A nurse is caring for a pt who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the pt on the floor. What is the priority nursing action? A. notify the provider of the fall B. call for help C. determine the pts LOC D. complete an incident report

C. determine the pt's LOC Rationales.. the pt might have had a vasovagal response while defecating, resulting in a temporary loss of consciousness that does not require CPR

A nurse is caring for a pt who asks if the pt in the next room is in pain bc she cries out frequently. Which of the following statements should the nurse make? A. that pt has cancer & is quite uncomfortable B. we are doing our best to keep that pt as comfortable as possible C. does the crying out bother you D. why don't you ask the pt's family when they visit

C. does the crying out bother you Rationales.. This therapeutic response focuses on the pt's feelings rather than on confidential info concerning the pt in the next room. It summarizes the pt's question & poses an open-ended, relevant query for the pt to expand on if desired A. revealing another pt's dx is an invasion of privacy & a violation of the HIPAA regulations B. this nontherapeutic statement by the nurse uses a defensive response. It ignores the pt's concerns bc the nurse is focusing on defending the health care team D. this nontherapeutic response by the nurse changes the subject & does not address the pt's concerns. It also ignores the right to privacy for the other pt

A nurse is preparing an IM injection for a pt who is preop when another pt suddenly calls for assistance. The nurse asks another nurse to give the injection since an assistive personnel is waiting to take the pt to surgery. Which of the following actions should the second nurse take? A. prepare a new syringe for the pt who is preop B. give the prepared med to the pt who is preop C. help the pt requesting assistance so the first nurse can give the prepared injection D. report this request to the charge nurse

C. help the pt requesting assitance so the first nurse can give the prepared injection Rationales.. The second nurse should help the other pt so the first nurse can give the injection. The nurse who has prepared the injection is the only on who can safely ID what is in the syringe and be responsible for correctly admin the med A. it is not necessary to waste the med that is already prepared B. a nurse should never give a med that another nurse has prepared. The nurse admin the med must prepare the med in order to confirm what the syringe contains D. this action is not necessary

A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is fiving preferential tx to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response this conflict? A. understanding that the unit nurse is misinformed & taking no action B. assigning the unit nurse to work the night shift to facilitate direct experience w/ the night shift C. meeting one on one w/ the unit nurse to discuss these concerns D. confronting the unit nurse during the next unit meeting regarding this statement

C. meeting one on one w/ the unit nurse to discuss these concerns Rationales.. The charge nurse should schedule a time to speak privately w/ the nurse nurse about the situation. Assertive behavior involves discussing a situation directly w/ the person involved A. avoidance by the charge nurse is a form of passive behavior, which does not solve the conflict B. a unit nurse should not be reassigned to the night shift for the purpose of gaining experience of the night shift. The charge nurse should provide guidance in this situation w/ the unit nurse in another manner D. the charge nurse should not confront the unit nurse about the situation in front of other staff members. This action can create further conflict between both parties & does not solve the present issue

A nurse is assisting w/ the informed consent process for a pt who is scheduled for a below-the-knee amputation's. The pt asks the nurse, "Why are they making me have this surgery? I don't understand why they are doing this." Which of the following actions should the nurse take? A. complete an incident report B. admin an antianxiety med C. notify the provider of the pt's comments D. answer the pts questions & verify understanding

C. notify the provider of the pt's comments Rationales.. It is the nurse's responsibility to notify the provider if the pt has questions / appears not to understand the procedure. The provider is responsible for providing clarification. Informed consent is a legal process by which a pt gives written permission for a procedure / tx

An experienced nurse is serving as a mentor to a newly licensed nurse. Which of the following actions should the mentor take? A. est. a set of goals for the newly licensed nurse to achieve B. est. a set timeframe w/ the newly licensed nurse for the mentorship process C. serve as a guide & teacher for the newly licensed nurse in an est. relationship D. develop a program of study for the newly licensed nurse to follow

C. serve as a guide & teacher for the newly licensed nurse in an est. relationship Rationales.. A mentor est. a nurturing relationship w/ a newly licensed nurse & is willing to invest time & resources to help this person develop as a nurse & an individual A. a mentor should assist the newly licensed nurse w/ setting & achieving realistic goals through support & guidance B. a mentorship does not have a determined timeframe. This is a characteristic of a preceptor, who is often assigned by the facility for a set amount of time D. developing a program of study for a newly licensed nurse to follow is not the responsibility of a mentor

A nurse is caring for a pt who is dying & unstable to make decisions for himself. The pt's adult kids disagree about his code status. Which of the following sources should the nurse depend on for decisions regarding the pt's end of life care? A. the pt's oldest child B. the attending provider C. the pt's health care proxy D. the facility's ethics committee

C. the pt's health care proxy Rationales.. If the pt connot speak for himself, the nurse should follow the directions of the pt's health care proxy, as this is the person the pt chose to make decisions under these circumstances A. if the pt does not have advance directives / has not named a health care proxy, the family may be asked to make end of life decisions B. the attending provider may offer suggestions on end of life care, but the pt or the pt's health care proxy directs treatment D. in the absence of advance directions, the facility's ethics committee may be called upon to intervene if a conflict occurs regarding end of life decisions

A nurse is following standard policy & procedure for reporting a pt who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC? A. clostridioides difficile B. candidiasis C. vancomycin-resistant staphylococcus aureus D. trichomoniasis

C. vancomycin-resistant staph aureus Rationales.. the nurse should follow policy & procedure for reporting a pt who has vancomycin-resistant S. aureus (a communicable disease) to the CDC. A. the nurse should implement contact precautions for a pt who has C. difficile; the nurse does not need to report this infection to the CDC B. the nurse should contact the provider to prescribed med to treat a candidiasis infection; the nurse does not need to report this infection to the CDC D. the nurse should inform the pt of the tx guidelines for trichomoniasis that are available from the CDC & provide teaching about the pt's prescription; trichomoniasis is not a communicable disease that needs to be reported to the CDC

A nurse overhears two other nurses discussing a conflict they are having about who should complete certain pt-care tasks. The nurses agree that they are tired of the conflict & will let the nurse manager decide who should complete the tasks. The nurse should ID this outcome as which of the following approaches to conflict management? A. win-win B. win-lose C. win-yield D. lose-lose

C. win-yield Rationales.. A win-yield approach involves both parties no longer trying to resolve the conflict. Instead of taking the initiative to end the conflict, they agree to honor whatever the nurse manager decides. A. win-win strategy is a collaborative approach. There is no power struggle, and both parties work together for a positive outcome that meets a common goal B. win-lose strategy involves one party emerging victoriously & the other losing the struggle. If the losing party continues to pursue the situation, it becomes a competing strategy D. lost-lost strategy is also an avoidance approach. The two parties abandon the struggle and take no further action, but the conflict remains. In this outcome, no one wins

A nurse is completing an incident report after administering an incorrect dose of med to a pt, even though the pt experienced no ill effects from the error. What is the purpose of completing the incident report? A. alerting the facility admin of a possible litigation situation B. tracking employee performance for possible disciplinary action C. providing a detailed report of the occurrence for the pt's family D. ID situations that contribute ot eh occurrence of med errors

D. ID situations that contribute to the occurrence of med errors Rationales.. the purpose of completing incidence reports is to ID factors that contribute to the occurrence of the problem. This one aspect of quality-improvement efforst in health care facilities A. incident reports are not completed to alter the facility admin of possible litigation situations B. using incident reports as a means for employee discipline will hinder the reporting of problems & inhibits the finding of solutions to improve the quality of pt care C. an incident report should not be given to the pt's family as a means of providing detailed info about the error

A nurse is working w/ an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? A. Whether the AP has consented to the performance of delegated tasks B. the pt's willingness to consent to care from the AP C. Whether the task can be more efficiently completed by the nurse D. The degree of supervision that the AP will required to complete the task

D. The degree of supervision that the AP will require to complete the task Rationales.... Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction & specification regarding the amount of supervision that will be provided. The right communication of expectations & the right feedback about performance must also be supplied. A. The nurse does not have to obtain consent from the AP when delegating tasks w/in the scope of practice & job descriptions for APs B. Tasks that can be delegated to an AP do not require the pt's consent C. One of the barriers to successful delegation is the belief that no one can do a tasks as efficiently & effectively as the nurse. Due to the time constraints on nurses, tasks that can be done by an AP should be duly delegated

A nurse manager is observing the staff members working on her unit. Which of the following actions should the nurse manager recognize as an example of paternalism? A. a nurse asking to care for an older adult pt every day who reminds the nurse of a favorite grandparent B. a male nurse caring for an adolescent male pt bc the pt is uncomfortable around female nurses C. a middle-aged adult AP mentoring a younger less-experienced AP on the unit D. a nurse practitioner withholding info from a pt who is dying to avoid causing the pt distress

D. a nurse practitioner withholding info from a pt who is dying to avoid causing the pt distress Rationales.. Paternalism is a type of relationship between pts & health care providers in which the health care providers believe they know what is best for the pts. In this ex, the nurse practitioner is making the decision for the pt & denying the pt the right to be informed

A nurse on a med surg unit is planning the care of assigned pts. Which of the following pt's should the nurse attend to first? A. a pt who is newly admitted & is scheduled for indwelling urinary catheter insertion B. a pt who has kidney stones & reports flank pain of 6 on a pain scale of 0-10 C. a pt dx w/ early stage chronic kidney disease w/ a serum creatinine level of 2.0 mg/dL D. a pt who has a cast newly applied on the forearm & reports tingling on the fingers

D. a pt who has a cast newly applied on the forearm & reports tingling of the fingers Rationales... When using the ABC approach to pt care, the nurse should first assess the pt who has a newly applied cast. Tingling, numbness, pallor, paresthesia, and pain are clinical s/s associated w/ compartment syndrome, a serious development in which increased tissue pressure in a confined anatomical space reduces blood flow, leading to ischemia, dysfunction, and eventual necrosis. The nurse should report this finding to the provider immediately

A nurse is selecting pt's for discharge following an environmental disaster. Which of the following pt's should the nurse select? A. a pt who has a cast removal due to compartment syndrome B. a pt who is scheduled for dialysis & has a potassium level of 6.2 C. a pt who has type 1 DM & a BGL of 320 D. a pt who is 1 day post op following an inguinal hernia repair

D. a pt who is 1 day post op following an inguinal hernia repair Rationales.. The nurse should select the pt who had an inguinal hernia repair for discharge bc this pt is stable A. a pt who has compartment syndrome needs continuous monitoring of the affected extremity B. a pt who is hyperkalemic & in need of dialysis may experience dysrhythmic complications from the electrolyte imbalance C. a pt who has type 1 DM & a BGL of 320 will need to be monitored to track blood glucose & the pts response to insulin therapy

An RN & a LPN are caring for a pt who has a small bowel obstruction & is NPO w/ a NG tube set to continuous suction. Which of the following tasks should the RN perform? A. obtain daily weight B. inspect the pt's oral cavity for dryness hourly C. measure & record the NG tube output every 4 hrs D. assess for bowel sounds every 2 hrs

D. assess for bowel sounds every 2 hrs Rationales.. Assessments are w/in the scope of practice for the RN only. While the LPN can also auscultate the pt's ABD for the presence of sounds, only the RN is qualified to even the sounds & qualify them as hypoactive, normal, or hyperactive A. obtaining a daily weight is w/in the scope of practice of an LPN. While the RN could also perform this task, it should be delegated to an LPN so that the RN is available to perform other tasks B. oral care is considered part of routine hygiene and includes observing the members of the mouth for dryness. It is w/in the scope of practice for the LPN. While the RN could also perform this task, it should be delegated to an LPN so the RN is available to perform other tasks C. measuring & recording the NG tube output is w/in the scope of practice for the LPN. While the RN could so perform this task, it should be delegated to an LPN so the RN is available to perform other task

A charge nurse finds an increased incidence of health care associated infections (HAIs) on a long term care unit. Which priority action should the charge nurse take to address the problem? A. monitor the staff's hand hygiene techniques B. hold a mandatory in service training session about hand hygiene & infection rates C. require nurses to take an online course on HAIs D. conduct a chart review to gather data about pts who developed HAIs

D. conduct a chart review to gather data about pts who developed HAIs Rationales.. The charge nurse should first conduct a chart review / audit in order to gather data about the pts who developed infections. This info will provide the charge nurse w/ potential indicators / fractos what resulted in the increased incidence of HAIs

A nurse is caring for a post op pt who has an Hgb of 8.0 g/dL. The nurse delegates the admin of a unit of packed RBCs to a nurse floating from a psychiatric unit who is unfamiliar w/ blood admin. Which of the following actions should the float nurse take? A. call the provider to clarify the prescription for administering the unit of packed RBCs B. hang the unit of blood if the charge nurse agrees to be a resource C. question the nurse regarding this prescription due to the pt's reported Hgb level D. decline to hand the blood

D. decline to hand the blood Rationales.. The nurse has a legal duty to decline tasks that cannot be performed safely & competently. A float nurse from a psychiatric unit would not be familiar w/ the current policy regarding blood admin, & this nurse has limited experience w/ this procedure. The tasks should be assigned to another nurse A. the nurse does not need to call the provided to clarify the prescription, which is appropriate for a pt w/ this Hgb level B. the nurse should accept tasks that can be preformed safely & competently C. the pt's Hgb is below the expected range & transfusions are appropriate

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the chance, and the nurse manager notes that this nurse does not deliver care according to the new policy. Which of the following actions should the nurse manager take? A. explain the disciplinary consequences of refusing to implement the new policy B. reinforce w/ the staff nurse the importance of implementing the policy change C. ignore the staff nurse's resistance & allow peer pressure to facilitate the change D. encourage the staff nurse to verbalize reasons for resisting the change

D. encourage the staff nurse to verbalize reasons for resisting the change Rationales.. The nurse manager should realize that if the nurses who must implement the change are not invested in the change process, resistance is likely. This is esp. problematic when the change in unplanned / imposed by outside forces. The resistance staff nurse has likely rejected the change due to prior habits, fear of the unknown, and lack of time to learn something new. A meeting between the nurse manager & the staff nurse will provide an open forum for the staff nurse to verbalize the reasons for reluctance in adopting the new policy A. taking an authoritative approach & threatening the nurse through the use of coercive power are not appropriate actions B. reinforcing the importance of the new policy w/ the staff nurse will not produce a behavior change, as this approach has already proven unsuccessful C. adopting a liassez-faire attitude toward the staff nurse in hopes that others will take responsibility for the nurse's behavior is not an appropriate action manager and will allow the behavior to continue indefinitely

A nurse manager observes a nurse entering the room of a pt who is on contact precautions w/out donning PPE. Which of the following is the priority action for the nurse manager to take? A. speak w/ the nurse in a private room B. complete an incident report C. review competencies w/ the staff members regarding PPE D. have the nurse exit the room and don proper PPE

D. have the nurse exit the room and don proper PPE Rationales.. The nurse manager should apply the safety and risk-reduction. The nurse manager should first ensure the safety of the staff & pts by having the nurse exit, don proper PPE, before re-entering the room

A nurse manager is implementing a team nursing approach on his unit, hiring LPNs & AP is additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change? A. develop a plan for the change & present it during a staff meeting B. explain that this change is a request from the admin & will be carried out C. hire new LPNs & APs & gradually integrate them into the staff D. introduce the new approach & facilitate the development of a task force to plan implementation

D. introduce the new approach & facilitate the development of a task force to plan implementation Rationales.. this appropriate approach involves the stiff in the planning & will give them a feeling of control over their practice & enhance acceptance of the change A. this approach to staffing change is authoritarian in nature. Involvement of staff in facilitating the change is more democratic & will enhance acceptance B. this approach will make nurses feel powerless & resentful. Additionally, removing staff from involvement in the change process will decrease acceptance of the change C. this approach is indirect & may precipitate feelings of mistrust. Role conflict may develop if the introduction of the new nurses & their roles in the unit are not discussed first w/ the existing staff

A nurse is receiving report on a pt who has C diff and is being transferred from another unit. Which of the following precautions should the nurse take? A. place the pt in a negative airflow room B. clean the pt's room w/ antibacterial disinfectant C. wear a mask when entering the pt's room D. perform hand hygiene w/ nonantimicrobial soap & water after pt care

D. perform hand hygiene w/ nonantimicrobial soap & water after pt care Rationales.. This spore-forming organism is resistant to alcohol-based soaps & sanitizers A. the nurse should place the pt in a private room to isolate the infection. If a private room is not available, the nurse should place the pt in a room w/ another pt who has the same infection B. the nurse should clean the pts room w/ a bleach solution. C diff is a spore forming organism that can remain on surfaces if not treated w/ a bleach solution C. the nurse does not need to wear to wear a mask when entering the pt's room because C diff is transmitted by contact. The nurse should wear a mask when a pt is in droplet / airborne isolation

A nurse is discussing palliative care w/ the family of a pt who is terminally ill. Which of the following should the nurse include as the purpose of palliative care? A. curing the disease B. producing remission C. hastening death D. providing comfort measures

D. providing comfort measures Rationales... palliative care is an approach to care that promotes comfort for a pt who has a terminal dx & is not receiving aggressive therapy. Palliative care focuses on managing s/s of the disease, not on curing the disease A. curing the disease is only possible when specific tx is available. Palliative care is only an option when there is no possibility of a cure or when a pt w/ a terminal disaease has refused tx B. if a remission is possible w/ tx, this should be offered to the pt before palliative care. Palliative care in only an option when there is no possibility of a remission / when a pt who has terminal disease has refused tx C. Palliative care is not intended to prolong / hasten death. Instead, it seeks to provide comfort for a pt who is terminally ill

A nurse manager notes that several staff members are late in completing an annual mandatory edu session about extremity restraint safety. Which of the following actions should the nurse manager plan to take? A. make a general announcement at the next staff meeting asks all employees to check their adherence to the requirement B. post a list in the employees' break room naming those who are non-adherent & the date by which they must complete the requirement C. schedule a disciplinary conference w/ each of the non-adherent employees D. send an email to each non-adherent employee that includes a link to upcoming edu sessions

D. send an email to each non-adherent employee that includes a link to upcoming educational sessions Rationales.. Email provides a simple yet efficient way for the nurse manager to inform non-adherent employees about options for achieving adherence w/out embarrassing anyone w/ a public announcement. In addition, including the appropriate like in the email facilitates adherence by helping each employee ID an upcoming session that coordinates w/ his/her work schedule A. this action does not address the specific employees who are non-adherent B. the employees might interpret this action as punitive & embarrassing for those who are non-adherent C. The nurse manager should delay scheduling a disciplinary conference unless the employees do not demonstrate the desired behavior after less punitive actions are taken

A nurse is teaching a newly licensed nurse about the informed consent process for a pt who is scheduled for a surgical procedure. Which of the following pieces of info should the nurse include in the teaching? A. clerical staff in the facility can witness the signature of a pt on a consent form B. the nurse caring for a pt is responsible for explaining the procedure C. a family member should be present when a pt signs a consent form D. the person who will perform the procedure is responsible for obtaining informed consent

D. the person who will perform the procedure is responsible for obtaining informed consent Rationales.. The person performing the procedure is legally responsible for obtaining informed consent. Informed consent includes telling the pt about the risks & benefits of the procedure, alternative txs available, & possible outcomes if the procedure is not performed A. clerical staff cannot witness a pt's signature on a consent form because they cannot ensure that the consent is informed B. the nurse caring for the pt is not responsible for explaining the procedure. Verifying that a signed consent form is in the medical record before the procedure & witnessing the pt's signature are responsibilities of the assigned nurse C. a family member does not need to be present for a pt to provide consent for a surgical procedure

A nurse on a med surg unit is delegated tasks to nursing team members. Which of the following tasks should the nurse delegate to an AP? A. instructing a pt how to use a glucometer B. instilling lubricated eye drops for a pt C. evaluating the effectiveness of a pt's pain med D. transferring a pt who is post op from a bed to a chair

D. transferring a pt who is post op from a bed to a chair Rationales.. Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, & other simple procedures that do not involve assessment / teaching

A nurse is ambulating a pt who has an IV w/ an infusion pump. After the nurse returns the pt to his room and plugs in the infusion pump, the pt reports a slight tingling in his hand. Which of the following actions should the nurse take? A. plug the pump into a different outlet B. place a service tag on the pump for a routine inspection C. unplug the pump & plug it back into the same outlet to see if the sensation of tingling is repeated D. turn off the pump

D. turn off the pump Rationales.. The pump must be turned off immediately to protect the pt & the nurse from the risk of electrical injury & fire. The nurse should consider any electrical equipment that shows of malfunction to be unsafe & place it out of service until it can be checked by the facility's maintenance department

A nurse is updating the plan of care for a pt who has celiac disease. Which of the following dietary selections should the nurse recommend for the pt? A. whole-wheat tortilla w/ black beans B. baked chicken & rice C. turkey & cheese sandwich D. pasta w/ marinara sauce

B. baked chicken & rice Rationales.. Pts who have celiac disease should avoid foods containing gluten

A nurse finds a pt standing next to his bed w/ the side rails raised. The pt is visibly confused & not wearing an ID bracelet, & his IV is detached. The pt states, "I can't remember my name." After assisting the pt back into bed, which of the following actions should the nurse take next? A. remind the pt to use the call light B. restart the IV C. assess the pt for injury D. put an ID bracelet on the pt

C. assess the pt for injury

A charge nurse is observing a group of newly licensed nurses. Which of the following actions should the charge nurse report to the nurse manager as a violation of HIPAA? A. assigning a pt who requested a private room to a semi-private room due to unavailability B. placing a pt who is confused in restraints C. talking about pts w/ other nurses in the cafeteria D. wheeling a pt who is wearing a sheet down the hall into the shower room

C. talking about pts w/ other nurses in the cafeteria Rationales.. The nurse should not discuss info about pts

A nurse is planning care for a pt who is newly admitted to the medical unit. Which of the following health care team members should the nurse plan to consult w/ regarding the benefit of chest physiotherapy for this pt? A. physical therapist B. occupational therapist C. speech-language pathologist D. resp therapist

D. resp therapist Rationales.. The nurse should collab w/ the resp therapist & the pt's provider to determine if chest physiotherapy (CPT) could benefit the pt. A complete resp assessment is necessary to confirm the need for CPT A. the nurse should consult a physical therapist for pts who need assistance r/t musculoskeletal problems B. the nurse should consult an occupational therapist for pt's who have impaired function of the skills necessary to complete ADLs C. the nurse should consult a speech-language pathologist for issues like difficulty swallowing / for pt's who are communicatively impaired