ATI Leadership Quizzes (NCLEX Practice)!!

A nurse from a medical unit is asked to work on an orthopedic unit. the medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?

A client who had a right above-the-knee amputation 24 hr ago (A nurse from a medical unit can care for this client because the surgical dressing is usually left in place for 48 to 72 hr, so the residual limb does not require special care at this time.)

a charge nurse is supervising the care of several clients. which of the following actions requires intervention by the charge nurse?

A student nurse is photocopying his assigned client's diagnostic test results (Photocopying diagnostic test results is a breach of the client's confidentiality and privacy.)

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first? A. Notify hospital security. B. Approach the man and ask why he is making copies. C. Inform the nursing supervisor D. Report the observation to the nurse caring for that client.

Approach the man and ask why he is making copies. Rationale: The first action the nurse should take using the nursing process is to assess the situation to determine whether this man is authorized to be in possession of the client's medical record to protect the client's confidentiality. Making copies from a client's medical record is allowed under specific circumstances. It is important to act in a timely fashion to protect the client's medical information. The nurse should approach the individual in a nonthreatening way to inquire about the copies being made.

A nurse receives notification of a fire on the unit. Which of the following should the nurse take first?

Assist clients who are in immediate danger to a safe location. (The greatest risk to clients is injury from the fire. Therefore, the first action the nurse should take is to move clients who are in immediate danger to a safe location.)

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? A. Collect a stool sample for ova and parasites from a school-age child B. Engage a toddler in play. C. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma. D. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate. Rationale: The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first.

a nurse is preparing to administer medication to a client who has Crohn's disease. The client states "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?

Inform the client of the consequences of refusing the medication. (The nurse should inform the client of the consequences of refusing the medication. It is the client's right to decide whether to take the medication. If the client still refuses after receiving further information, the nurse should waste the medication and document the occurrence in the client's medical record.)

A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing the issue?

Inform the staff of the penalties that can result from medication errors. (The nurse manager is using penalties to promote behavior change; this is characteristic of authoritarian leadership.)

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism B. Nonmaleficence C. Fidelity D. Veracity

Nonmaleficence

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first? A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. B. Apply a condom catheter to a client who is incontinent. C. Feed a client who has bilateral casts due to upper arm fractures. D. Deliver a clean voided urine specimen to the laboratory

Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority task to delegate is the blood glucose monitoring for the client who has an insulin prescription. This task is time sensitive and should be completed first.

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Review the AP's skill competency checklist. (A review of the AP's checklist should validate that they have demonstrated the ability to safely perform the procedure.)

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? A. Right circumstances B. Right communication C. Right person D. Right supervision

Right supervision Rationale: The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.

A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change? A. Assess the problem. B. Use tactics to alert staff nurses that a change is needed. C. Evaluate the effectiveness of the change. D. Set a target date.

Set a target date. Rationale: During the moving stage, the charge nurse should develop the plan for change and set the target date.

A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?

This is a procedure that does not require a written informed consent. (The client does not need to sign an informed consent form for insertion of an indwelling urinary catheter. The client gives implied consent by complying with the procedure.)

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? A. Complete an incident report. B. Request the risk manager obtain consent for HIV testing from the client. C. Wash the site of injury with soap and water. D. Consent to postexposure treatment with antiretroviral medications.

Wash the cite of injury with soap and water Rationale: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.

A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom? A. The nurse manager B. No one C. A nursing student who is completing a preceptorship on the unit D. The unit clerk

no one Rationale: Computer passwords cannot be shared with others for any reason. Any facility employee authorized to have access to the database on a computer will have a personal password.

Which of the following instruction provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel?

"Check the urinary output at 1100 for John Doe and report it to me immediately." (This instruction follows the Five Rights of Delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for collection, and the expectation for communicating the findings back to the nurse.)

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation? A. "Delegation provides appropriate resources for the client." B. "Delegation permits a designated individual to meet a goal on your behalf." C. "Delegation promotes discharge teaching activities for clients." D. "Delegation decreases health care costs."

"Delegation permits a designated individual to meet a goal on your behalf." Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching? A. "Disaster drills should be held on a regular basis." B. "An actual disaster cannot take the place of a disaster drill." C. "A staff nurse can function as the incident commander." D. "A physician must triage victims of a disaster in the emergency department."

"Disaster drills should be held on a regular basis." Rationale: Hospitals should perform disaster drills on a routine basis to ensure effective response in the event of a disaster.

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching? A. "Do not adjust the oxygen flow rate." B. "Check your oxygen equipment once each week." C. "Store unused oxygen tanks horizontally." D. "Use wool blankets on your bed."

"Do not adjust the oxygen flow rate." Rationale: The nurse should instruct the client not to adjust the oxygen flow rate to ensure that the client receives the prescribed rate

A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)? A. "HICS ensures that necessary antibiotics and antidotes are available." B. "HICS is focused on having multidisciplinary responders available." C. "HICS identifies facility responsibilities and channels of reporting." D. "HICS provides additional responders when needs exceed the ability of local or state agencies."

"HICS identifies facility responsibilities and channels of reporting." Rationale: HICS identifies responsibilities and channels of reporting within the facility to provide a uniform response plan among facilities.

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? A. "It is time to sign the consent so your treatment can begin." B. "I would not have this type of surgery if I were you." C. "Have you discussed other treatments with your provider?" D. "I can inform the surgeon you do not want the surgery."

"Have you discussed other treatments with your provider?" Rationale: The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure.

A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness? A. "I feel as though I met the standard of care. Would you tell me more about your concerns?" B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I am at a loss for words. I always do my best to give good care to my clients." D. "What do you have against me? It must be something or you wouldn't be criticizing my care."

"I feel as though I met the standard of care. Would you tell me more about your concerns?" Rationale: Communicating assertively is expressing thoughts in an open, honest, and direct manner that demonstrates respect for self and others. The use of "I" statements, maintaining eye contact, and congruent verbal and facial expressions are all components of assertiveness skills. The nurse demonstrates respect for the opinion of the other nurse by asking for feedback and the reason for the concerns.

A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? A. "I have my assignment and will start with room 1, then work my way to room 10." B. "I will give this client his meal tray first, as he is going early to physical therapy." C. "After breakfast, I will pack the belongings of clients who will be discharged this morning." D. "I will start by providing partial baths before breakfast."

"I have my assignment and will start with room 1, then work my way to room 10." Rationale: The AP's statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized.

A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN? A. "I do not know how to make the remote control work." B. "Do you know when I will be going home?" C. "My dressing was changed earlier this morning." D. "I have not received any of my medications today."

"I have not received any of my medications today." Rationale: Failure to receive prescribed medications in a timely manner can have a negative effect on client outcomes. The nurse should immediately follow up with the PN to determine if medications have been administered and, if not, to learn why. It is possible that the client does not remember receiving medications or that no medications were been prescribed as of this time. Effective supervision requires that any issue that can negatively impact client care is followed up on immediately.

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about his type of advance directive. Which of the following statements by the client indicates a need for clarification? A. "I can change who I designate as my health care proxy at any time." B. "If I become incapacitated, end-of-life choices will be made by my proxy." C. "I have to choose a family member as my health proxy." D. "The health care proxy does not go into effect until I am incapable of making decisions."

"I have to choose a family member as my health proxy." Rationale: The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.

A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? A. "I feel you are being inconsiderate of the other team members." B. "I have to let the director of nursing know about this situation." C. "I need to talk to you about the unit policies regarding client assignments." D. "You always get your choice of assignment and don't work your fair share."

"I need to talk to you about the unit policies regarding client assignments." Rationale: This statement opens the conversation in a nonthreatening way and places the focus on the issue of policies rather than on any personal desire or characteristic of the individual.

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on the next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? A. "I need to talk to you about unit expectations regarding delegating and completing tasks." B. "Several staff members have commented that you don't do your fair share of the work." C. "If you don't do your share of the work, I will have to inform the nurse manager." D. "You have been very inconsiderate of others by not completing your share of the work.

"I need to talk to you about unit expectations regarding delegating and completing tasks"

A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication? A. "I had strep throat about one year ago." B. "I plan to continue nursing my baby until he is at least a year old." C. "I got my flu shot at the pharmacy two weeks ago." D. "I am allergic to shellfish."

"I plan to continue nursing my baby until he is at least a year old." Rationale: Glyburide is a sulfonylurea that is used to treat type 2 diabetes, but it is contraindicated during pregnancy and breastfeeding.

A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "I should wait to empty my client's drainable colostomy until it is three-fourths full." B. "I should delegate providing closed irrigation to the assistive personnel (AP)." C. "I should encourage clients to receive an annual flu immunization." D. "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care."

"I should encourage clients to receive an annual flu immunization." Rationale: Cost containment is the delivery of effective and efficient care. Cost is maintained without loss of quality. The nurse should encourage clients to receive an annual flu immunization to prevent the need for treatment and hospitalization necessary with influenza.

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? A. "I will have to be admitted to a long-term care facility in order to receive hospice care." B. "I should expect the hospice team to help me manage my dyspnea." C. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." D. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."

"I should expect the hospice team to help me manage my dyspnea." Rationale: Dyspnea is a manifestation of terminal lung cancer. The p

a nurse is caring for a 19 year old client who has been informed that their cancer has metastasized. The Client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make?

"I will gather information about palliative care for you." (The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options.)

A nurse manger is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manger is appropriate? A. "If you render aid in an accident, do not leave the scene until another competent person can take over." B. "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse." C. "Federal laws require a licensed nurse to render aid in an emergency." D. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws."

"If you render aid in an accident, do not leave the scene until another competent person can take over." Rationale: Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate? A. "You should think about how you make others feel when you lose your temper." B. "I will help you with this procedure instead of the staff nurse." C. "It must be very frustrating when you don't have want you need to perform the procedure." D. "If you let us know ahead of time that you plan to perform a procedure, we could do a better job of having the supplies available."

"It must be very frustrating when you don't have want you need to perform the procedure." Rationale: The charge nurse is acknowledging the provider's frustration when making this statement. This can lead to resolution of the conflict.

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate? A. "Let's talk about your concerns about the new policy." B. "Why didn't you voice your concerns before the new policy was implemented?" C. "Being open to change is an expectation of the nurses who work on this unit." D. "You should support this policy change because it was based on evidence-based practice."

"Let's talk about your concerns about the new policy." Rationale: The nurse manager should meet with the nurse to allow an open forum for the nurse to verbalize the reasons for her reluctance to adopt the new policy.

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse? A. "Let's talk about something else." B. "Whether or not I am a good lover is irrelevant." C. "Speaking to me like that makes me uncomfortable." D. "You need to lower your voice. Others can hear you."

"Speaking to me like that makes me uncomfortable." Rationale: This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.

A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make? A. "I will ask the nursing supervisor to obtain the medical records for you." B. "The health care provider will share this information with you." C. "The ethics committee will need to approve this request for you." D. "The client must provide permission to share the records with you."

"The client must provide permission to share the records with you." Rationale: Client information is shared only with individuals involved directly in the client's care. The client must provide permission for the family to access protected health information.

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? A. "The client should be seen by a neurologist." B. "The client was found unconscious on the floor in her home." C. "There are no provider's prescriptions available." D. "The client is disoriented. Pupils are slow to respond to light."

"The client was found unconscious on the floor in her home." Rationale: This statement is the background or context of the situation, which is the B step in the SBAR tool. The background portion should provide information that is pertinent to the current situation.

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)? A. "The client's family members have been present most of the day." B. "The client's blood pressure and pulse have been fluctuating throughout the day." C. "The client discussed having prior thoughts of suicide." D. "The client works in the hospital radiology department."

"The client's blood pressure and pulse have been fluctuating throughout the day." Rationale: Knowing the client and the stability of his condition is a criterion to consider when delegating to the AP. To promote client safety, the more stable clients should be chosen when delegating tasks to APs.

A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "The nurse relinquishes accountability for client outcomes when care is delegated to an AP." B. "The AP can provide client education about how to perform basic self-care to the client." C. "The nurse should consider the AP's level of experience when making delegation decisions." D. "The AP can re-delegate a task to another AP who has similar work experience."

"The nurse should consider the AP's level of experience when making delegation decisions." Rationale: When delegating a task, the nurse should delegate the task to the right person. The nurse should consider the AP's job description, level of knowledge, and individual level of experience.

An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? A. "There is a higher risk of infection for our clients associated with artificial nails." B. "You should know that artificial nails have a very unprofessional appearance." C. "I want you to review the facility's policy on personal attire before you begin the shift." D. "Why would you wear artificial nails to work when you know it's against the rules?"

"There is a higher risk of infection for our clients associated with artificial nails." Rationale: Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.

A nurse is caring for a client has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the clients family about organ donation. The clients spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?

"What do you think your spouse would have wanted?"

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." B. "What do you think your spouse would have wanted?" C. "Most religions support organ donation, so don't let that stand in the way." D. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

"What do you think your spouse would have wanted?" Rationale: Federal law requires facilities to have policies and procedures in place about making a request for organ and tissue donation at the time of death. The request is made by an employee, often a social worker, who has advanced training and can request the donations in a caring, sensitive manner. The role of the nurse is to provide emotional support to the family. Family members should consider the deceased person's wishes when making their decision.

A nurse on a medical-surgical unit has arrived late to work multiple times over the past several weeks. The nurse manager is planning to use progressive discipline to address this problem. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

- Schedule a meeting with the nurse -provide a written reprimand -Temporarily remove the nurse from shifts -Terminate the nurse's employment (The first step of the progressive discipline process is counseling the employee. The manager should set up a meeting with the nurse to ensure the nurse understands the expectations of the position. The manager should explain what the nurse must do to correct the behavior. If it continues, the manager should proceed to a written reprimand, which the manager and the nurse must sign to acknowledge that they discussed the issue. If the nurse's performance still does not improve, the manager should proceed with suspension. If the problem continues, the manager should terminate the nurse's employment.)

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse do? (Select all that apply.)

-Role model a positive approach to the changes is correct -Encourage staff members who support the changes to discuss the issue with resistant staff is correct

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.)

-The right to be treated with respect and dignity -The right to refuse their medications -The right to leave regardless of provider recommendations -The right to be fully informed of their health conditions

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients? A. A child who is experiencing sickle cell crisis B. A child who has streptococcal pharyngitis C. A child who has a head injury D. A child who has a new diagnosis of type 1 diabetes mellitus

A child who has a new diagnosis of type 1 diabetes mellitus Rationale: The nurse should place these clients together. It is appropriate because the child who has diabetes requires monitoring and teaching and the child who is postoperative from an appendectomy requires frequent assessments and interventions.

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? A. A client who is a 1 day postpartum after a late term miscarriage B. A client who had a bilateral tubal ligation 12 hr previously C. A client who is 4 days postpartum and has mastitis D. A client admitted 1 hr ago for an ectopic pregnancy

A client admitted 1 hr ago for an ectopic pregnancy Rationale:A client who has an ectopic pregnancy is unstable. The client is at risk for rupture of the fallopian tube, hemorrhage, and shock. Nursing care requires frequent monitoring every 15 min, IV access for fluid resuscitation. The client may also require blood transfusions, oxygen, and pain management. Therefore this client is the highest priority.

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? A. A client who needs assistance with a bath B. A client requesting a referral for home health services C. A client asking about his PCA pump that contains morphine D. A client who has questions about his new prescription

A client asking about his PCA pump that contains morphine Rationale: Clients who are administered morphine are at risk for respiratory distress. When using the urgent vs. nonurgent approach to client care, this is the client the nurse should care for first.

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. B. A staff member does not show up to work her assigned shift. C. A client discovers that his dentures are missing. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.

A client discovers that his dentures are missing. Rationale: This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first? A. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided C. A client who has COPD and the capillary refill time on both hands is 4 seconds D. A client who has late-stage cirrhosis and whose breath has a fruity odor

A client who had an indwelling urinary catheter removed 5 hr ago and has not voided Rationale:After removal of an indwelling urinary catheter, the client should void within 4 hr. If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore, when using the priority-setting framework of urgent vs. nonurgent, this client should be assessed first because he has not voided for 5 hr.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A. A client who has diarrhea and requests clear liquids for breakfast B. A client who has a cast on the left leg and reports numbness and paresthesia C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has a cast on the left leg and reports numbness and paresthesia Rationale: The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.

A nurse is caring for four clients. Which of the following assessment findings is the priority?

A client who has a femur fracture and reports feeling short of breath (When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is a client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep-vein thrombosis, which can lead to pulmonary embolism.)

A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP? A. A client who has a lumbosacral spinal tumor B. A client who has Guillain-Barre syndrome C. A client who has amyotrophic lateral sclerosis (ALS) D. A client who has systemic sclerosis

A client who has a lumbosacral spinal tumor Rationale: The nurse should delegate a task to the AP that is safe for a specific client. The client who has a lumbosacral spinal tumor is not at risk for dysphagia; therefore, the nurse should delegate meal assistance to the AP for this client.

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A. A client who has a punctured femoral artery B. A client who has multiple fractures C. A client who has a red rash over his abdomen D. A client who reports severe flank pain radiating to the groin

A client who has a punctured femoral artery Rationale: A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged

a nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?

A client who has a sucking chest wound (A client who has a sucking chest wound has an immediate threat to life and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend the provider evaluate this client first.)

a nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who has peripheral vascular disease and has an absent pulse in the right foot (When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is an absent pulse, which indicates no blood flow to the extremity.)

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? A. A client who has a splinted open fracture of left medial malleolus B. A client who has a massive head injury and is experiencing seizures C. A client who has severe respiratory stridor and a deviated trachea D. A client who has a small circular partial-thickness burn of the left calf

A client who has severe respiratory stridor and a deviated trachea Rationale:A client who has severe respiratory stridor and a deviated trachea is unstable. This client is triaged as emergent, and requires immediate attention to survive. This client has manifestations of a tension pneumothorax and airway obstruction. Therefore, this client is the highest priority for the nurse to assess.

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight B. A client who has terminal cancer and needs assistance with pain management C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work D. A client who has dementia and needs help with activities of daily living

A client who has terminal cancer and needs assistance with pain management Rationale:A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients? A. A client who is 1 hr postoperative following a thyroidectomy B. A client who is 2 hr postoperative following an abdominal hysterectomy C. A client who is 3 days postoperative following gastric bypass surgery D. A client who is 3 days postoperative following a craniotomy

A client who is 3 days postoperative following gastric bypass surgery Rationale: The client's physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. This client is 3 days postoperative and his condition would have stabilized by this time.

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN? A. A client who has terminal end-stage renal disease B. A client who has acute pancreatitis C. A client who is one-day postoperative following a total abdominal hysterectomy D. A client who had a stroke and is to be admitted

A client who is one-day postoperative following a total abdominal hysterectomy Rationale: The nurse who floats to another unit must have the skills to provide safe care to clients. This client is stable. This is an appropriate assignment for the RN.

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first? A. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL C. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output

A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL Rationale: When using the acute vs. chronic approach to client care, the nurse should first assess the client who has diabetes and takes glipizide. An adverse effect of glipizide is hypoglycemia and a blood glucose level of 68 mg/dL is below the expected reference range; therefore, this is the client the nurse should assess first.

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority? A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg Rationale:A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse's priority

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances? A. A dependent adult admitted for the treatment of a spiral fracture B. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse C. A young adult client admitted for acute glomerulonephritis following a viral infection D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

A dependent adult admitted for the treatment of a spiral fracture Rationale: Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult.

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A. An adolescent female client who is belligerent and has slurred speech B. A toddler who has a laceration on his forehead and is screaming C. A middle adult male who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn of his face and arms

A middle adult male who is diaphoretic and reports epigastric pain Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction.

A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence? A. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. B. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. C. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.

A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. Rationale:Professional negligence is performing practice below the expected standard of care. It can be an act of omission, which is the failure to perform an act that a reasonable prudent person, under similar circumstances, would do. A reasonably prudent nurse would notify the provider of the neurovascular finding immediately

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min B. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication

A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough Rationale:A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? A. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy B. An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax C. A middle adult who is 36 hr postoperative from an open laminectomy D. An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32

A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy Rationale: A client who is scheduled for an elective surgery is medically stable and is not bedridden; therefore, the nurse should recommend this client for discharge.

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.) A. Accompany a client who has depression to occupational therapy. B. Assess a client who has hypomania for exhaustion. C. Check the position of a client in soft wrist restraints. D. Set limits with a client who has mania. E. Sit with a client who has alcohol use disorder and whose last drink was five days ago.

A. Accompany a client who has depression to occupational therapy. C. Check the position of a client in soft wrist restraints. E. Sit with a client who has alcohol use disorder and whose last drink was five days ago. Rationale:Accompany a client who has depression to occupational therapy is correct. Accompanying a client to occupational therapy is within the scope of practice of an AP.Assess a client who has hypomania for exhaustion is incorrect. Assessment of a client requires specialized knowledge and is an activity that cannot be delegated.Check the position of a client in soft wrist restraints is correct. Checking the position of a client in soft wrist restraints is within the scope of practice of an AP. The position can be reported to the nurse for follow-up.Set limits with a client who has mania is incorrect. Implementing the plan of care requires specialized knowledge and is an activity that cannot be delegated.Sit with a client who has alcohol use disorder and whose last drink was five days ago is correct. Sitting with a client is within the scope of practice of an AP. Any changes in the client can be reported to the nurse for follow-up.

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.) A. Ambulate an older adult client who has hypertension. B. Provide discharge instructions for a client who has a new skin graft. C. Perform an admission assessment on a client. D. Check a blood product with another nurse prior to administration. E. Weigh a client who has heart failure.

A. Ambulate an older adult client who has hypertension. E. Weigh a client who has heart failure. Rationale: Ambulate an older adult client who has hypertension is correct. An AP can ambulate an older adult client who has hypertension.Provide discharge instructions for a client who has a new skin graft is incorrect. An RN should provide discharge teaching for a client.Perform an admission assessment on a client is incorrect. An RN should perform an admission assessment on a client.Check a blood product with another nurse prior to administration is incorrect. Two RNs or one RN and one licensed practical nurse (LPN) should check a blood product before administration.Weighing a client who has heart failure is correct. An AP can weigh a client who is stable.

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) A. The date of the incident B. The name of the provider who prescribed the medication C. The potential adverse effects of the medication D. The time the client was to receive the medication E. The client's vital signs

A. The date of the incident D. The time the client was to receive the medication E. The client's vital signs Rationale: The date of the incident is correct. When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date.The name of the provider who prescribed the medication is incorrect. The nurse does not need to include the name of the provider who prescribed the medication as this information is part of the client's medical record.The potential adverse effects of the medication is incorrect. The nurse should only include factual information about the incident and not potential effects.The time the client was to receive the medication is correct. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication.The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report.

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager? A. Ask other staff nurses about the level of care the specific staff nurse provides. B. Address the concern with the specific staff nurse. C. Recommend the specific staff nurse be transferred to another unit. D. Notify the human resources department about the request.

Address the concern with the specific staff nurse. Rationale: The nurse manager should use the conflict management skill collaborating to resolve the conflict. The nurse manager should be assertive and ask the specific staff nurse about the problem.

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

Advise the client to install grab bars in her bathroom at home. (The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls.)

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment? A. Ask each nurse to read the procedure and sign a form acknowledging competency. B. Allow time during the workday when each nurse can demonstrate proficiency. C. Require each nurse to take a written examination about the new equipment. D. Verbally question the staff about the new equipment.

Allow time during the workday when each nurse can demonstrate proficiency. Rationale: According to evidenced-based practice, the best action to evaluate competency with a psychomotor skill is by return demonstration. Ensuring that each nurse knows how to use the equipment through return demonstration is the best way to measure correct use of the new equipment. Prior to full implementation of any new equipment, the supervisory team should allow time for training and proficiency checks to ensure that client care is not compromised.

A nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict? A. Nurses on the unit disagree about what time of day daily client weights should be obtained B. A nurse is uncertain about joining a professional nursing organization C. A nurse who just lost his spouse does not want to be assigned to care for a terminally ill client D. An experienced nurse is uncivil to a newly licensed nurse

An experienced nurse is uncivil to a newly licensed nurse Rationale:Incivility and bullying are examples of interpersonal conflict. Interpersonal conflict arises from differing goals and value systems.

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A. A school-age child who has diabetes mellitus and requires blood glucose monitoring B. An infant who has pertussis and is receiving oxygen via nasal cannula C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions D. A toddler who has both arms in casts and needs to be fed his breakfast

An infant who has pertussis and is receiving oxygen via nasal cannula Rationale: Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? A. An expert nurse provides testimony that the nurse should have handled the situation differently. B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. C. The client's attorney states that injury to the client could have been prevented. D. The client's provider testifies the nurse was at fault for the injury

Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. Rationale: The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.

A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take? A. Take the specimen to the laboratory. B. Report the AP to the charge nurse. C. Complete an incident report. D. Ask the AP about her concerns with the assignment.

Ask the AP about her concerns with the assignment. Rationale: Reviewing the incident with the AP allows the nurse to understand the delegated task from the AP's perspective. The nurse should attempt to determine the underlying problem the AP has with the assignment.

A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?

Ask the client to explain the procedure that is being performed. (The nurse should ask the client to explain the procedure that is being performed. This allows the nurse to verify the client's understanding of the information provided by the provider prior to witnessing the client's signature on the consent form.)

A client on a general surgical unit tells a nurse that staff members are not answering his call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first?

Ask the client to verbalize his expectations. (The first action the nurse should take using the nursing process is to assess; therefore, the first action the nurse should take is to assess the client's feelings and clarify expectations.)

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? A. Ask what she will be assigned to do. B. Determine if she has the skills to complete the assignment. C. Identify her options. D. Notify the nurse manager about her concerns for client safety.

Ask what she will be assigned to do. Rationale: Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available to her.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? A. Taking a telephone prescription about a client who is to be transferred from PACU B. Assessing a client who experiences unilateral calf pain when ambulating C. Reinforcing a client's dressing for the surgical site of an above-the-knee amputation D. Reassuring the partner of a client who sustained a closed head injury

Assessing a client who experiences unilateral calf pain when ambulating Rationale: When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is assessing a client who has manifestations of a deep vein thrombosis, which can lead to pulmonary embolus. The nurse should assess this client and report the findings immediately to the provider.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? A. Situation B. Background C. Assessment D. Recommendation

Assessment Rationale: The nurse should include his assessments in this level of the report. For example, the client's oxygen saturation level and the client's apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? A. Assigning two assistive personnel (AP) to ambulate all clients B. Assigning a new graduate nurse to perform a wet-to-dry dressing change C. Assigning the most efficient AP to perform glucometer monitoring for each client D. Assigning the most competent RN to perform a central line dressing change

Assigning the most efficient AP to perform glucometer monitoring for each client Rationale:Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.

A nurse is caring for a terminally ill client who is receiving nutritional support. The clients adult children disagree about continuing nutritional support. THe dilemma is referred to the ethics committee. The nurse should expect which of the following actions from the ethics committee?

Assist in weighing the options involved in the decision. (Ethics committees are members of the interprofessional team who assist with problem solving related to ethical dilemmas. The ethics committee examines all of the facts and provides support for the clients and caregivers.)

A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)? A. Developing the plan of care for a client who has an amputation B. Evaluating the outcomes of a new postoperative client C. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus D. Assisting a client with crutch walking following knee replacement surgery

Assisting a client with crutch walking following knee replacement surgery Rationale: Assisting a client with crutch walking is within the LPN's scope of practice

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Justice

Autonomy Rationale: The issue here is the client's right to choose. The ethical principle of autonomy applies to an individual's right to choose and control what happens to him. Respecting autonomy requires the nurse to recognize the client's choice is based on personal values and those values do not have to be shared by the nurse.

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.) A. Demonstrate the technique to instill eye drops. B. Ambulate a client who has a cane. C. Irrigate a wound. D. Transfer a client to a stretcher. E. Record urinary output

B. Ambulate a client who has a cane. D. Transfer a client to a stretcher. E. Record urinary output. Rationale: Demonstrate the technique to instill eye drops is incorrect. It is not within the scope of practice for an AP to demonstrate medication administration. An RN should perform a task that requires client teaching.Ambulate a client who has a cane is correct. Ambulating a client who has a cane is within the scope of practice for an AP.Irrigate a wound is incorrect. It is not within the scope of practice for an AP to irrigate a wound. An RN should perform this task.Transfer a client to a stretcher is correct. Transferring a client to a stretcher is within the scope of practice for an AP.Record urinary output is correct. Recording urinary output is within the scope of practice for an AP

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) A. Provide discharge instructions to a confused client's spouse. B. Obtain vital signs from a client who is 6 hr postoperative. C. Administer a tap-water enema to a client who is preoperative. D. Initiate a plan of care for a client who is postoperative from an appendectomy. E. Catheterize a client who has not voided in 8 hr.

B. Obtain vital signs from a client who is 6 hr postoperative. C. Administer a tap-water enema to a client who is preoperative E. Catheterize a client who has not voided in 8 hr. Rationale: Providing discharge instructions to a confused client's spouse is incorrect. The nurse is responsible for delegating a task to the person who has proper training and skill. Client education is the responsibility of the registered nurse.Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN.Administering a tap-water enema to a client who is preoperative is correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN.Initiating a plan of care for a client who is postoperative from an appendectomy is incorrect. Planning care is the responsibility of the registered nurse.Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? A. Assault B. False imprisonment C. Negligence D. Battery

Battery Rationale:Battery is physical contact without the client's consent. Administering a medication against a client's wishes is an example of battery.

A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform? A. Administration of an enema B. Application of antiembolic stockings C. Assessing a client's sacrum for edema D. Assisting a client to cough and deep breathe

C. Assessing a client's sacrum for edema Rationale:Assessment requires the nurse's specialized knowledge and cannot be delegated to an AP

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) A. Raise all side rails on the client's bed. B. Obtain a prescription to restrain the client PRN. C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg.

C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg. Rationale: Raise all side rails on the client's bed is incorrect. Raising all side rails is considered a restraint. For a client who is disoriented, the risk for injury is greater with all side rails of the bed raised. If the client attempts to get out of bed, she may try to climb over the side rail or climb out at the foot of the bed. The nurse should place the bed in the lowest position.Obtain a prescription to restrain the client PRN is incorrect. Restraints are not prescribed PRN. Written restraint prescriptions are for a specific event and must have start and end times. Temporary restraints might be needed for clients who are confused, disoriented, repeatedly fall, or try to remove medical devices.Check on the client hourly is correct. Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach.Instruct the client about the use of the call light is correct. Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use.Apply an ambulation alarm to the client's leg is correct. The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.) A. Establish that the client is able to pay for the surgical procedure. B. Explain the surgical procedure to the client. C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary.1

C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary. Rationale: Establish that the client is able to pay for the surgical procedure is incorrect. The client's ability to pay for the procedure is not required prior to obtaining an informed consent.Explain the surgical procedure to the client is incorrect. It is the surgeon's responsibility to explain the procedure to the client.Validate the signature is authentic is correct. The nurse must validate the signature on the consent is made by the client or the client's legal guardian.Verify that the client understands the surgical procedure is correct. The nurse should verify the client understands the procedure and the risks.Confirm that the consent is voluntary is correct. The nurse should confirm the client is giving voluntary consent without coercion.

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A. Call the emergency response team. B. Seek immediate help from the risk manager. C. Call the provider for a stat DNR order. D. Respect the family's wishes and do nothing.

Call the emergency response team. Rationale: Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure.

a nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

Change-of-shift report can be given at the client's bedside. (Change-of-shift report is often given at the client's bedside to help protect the client's privacy. This allows the client to be involved with their care. The nurse should avoid giving report in public areas, such as in the hallway.)

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform the charge nurse that the client refused the enema.

Check the client's medical record for the provider's prescription. Rationale: The nurse should use the client's medical record to verify the provider prescribed an enema for the client.

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the CN make?

Clients are the experts on their own pain. (This response is appropriate because it indicates the nurse understands that the client's report is the best indicator of pain and is not making any assumptions.)

A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Clients on a mental health unit can refuse their medication.

A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program? A. Proper foot care will be demonstrated to clients during the program. B. Clients will have a decreased incidence of foot amputations. C. A facility will be reserved for the program. D. Handouts and teaching materials will be distributed at the program

Clients will have a decreased incidence of foot amputations. Rationale: A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program.

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure ulcers in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

Compare data from clients' records regarding skin integrity with established criteria. (Chart audits are an efficient and accurate way to measure if a change in a performance improvement indicator has occurred after an intervention is implemented.)

A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes? A. Establish a benchmark to identify a standard of performance. B. Compare the number of medication errors before and after the action was implemented. C. Provide the staff with a questionnaire to quantify staff satisfaction with the changes. D. Conduct a study about the time and money costs of implementing the change.

Compare the number of medication errors before and after the action was implemented. Rationale: Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions.

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following? A. Determines the client does not have a mental illness B. Confirms the client appears competent to provide consent C. Asserts the nurse has explained the risks and benefits of the procedure D. Records that the client's spouse agrees the procedure is necessary

Confirms the client appears competent to provide consent Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent.

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management? A. Avoiding B. Competing C. Compromising D. Cooperating

Cooperating Rationale: The charge nurse displayed cooperating, which is the resolution of the conflict by sacrificing. In this situation, it allowed both staff nurses to get what they wanted.

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate? A. "Tell me why you feel hopeless." B. "I am sure these feelings will pass once you go home." C. "If I were you, I would ask for a referral to hospice care." D. "Tell me what you understand about your illness."

D. "Tell me what you understand about your illness." Rationale: The nurse should use this statement to encourage the client to express her feelings and concerns.

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly? A. Provide a written procedure for the use of the device for the staff to review. B. Demonstrate using the device and observe the staff returning the demonstration. C. Remind the staff to review the procedure manual prior to using the new pump. D. Identify the differences and new features of the device in a written brochure.

Demonstrate using the device and observe the staff returning the demonstration. Rationale: The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.

a nurse is assigned care for four clients. Which of the following should the nurse plan to delegate to an assistive personnel (AP)?

Determine a client's intake and output. (The nurse can delegate determining a client's intake and output to an AP, as this does not require the use of the nursing process and is within the range of function of an AP.)

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Determine goals and objectives. (According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals.)

A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take? A. Verify the AP's educational preparation prior to delegating the task. B. Determine the time frame the AP should report the results. C. Observe the AP as she obtains the vital signs of each client. D. Ask the AP to take the vital signs of the client returning from surgery first.

Determine the time frame the AP should report the results. Rationale: The right communication is one of the five rights of delegation. The nurse should communicate with the AP and provide direction as to when the AP should report the findings of the vital signs.

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? A. Ensuring the charge nurse is available to witness the client's signature on the consent form B. Explaining the risks involved with the procedure C. Discussing alternate treatment options D. Determining the client's level of understanding about the procedure

Determining the client's level of understanding about the procedure Rationale:In the role of client advocate, the nurse is responsible for ensuring the client understands the information provided by the surgeon and must notify the surgeon if the client has questions.

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process? A. Complaint phase B. Discovery phase C. Decision phase D. Trial phase

Discovery phase Rationale: During the discovery phase, both attorneys for the plaintiff and the defendant obtain relevant information about the case. This includes witnesses' depositions.

Client is considering having tubal ligation and reports being uncertain if it is the right thing to do. which of the following actions should the nurse take?

Discuss the client's feelings about the procedure.

A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

Discuss with the client his concerns about having the surgery. (The nurse should ask the client relevant questions to determine their concerns regarding having the surgery. By asking relevant, open-ended questions, the nurse can help the client clarify their thoughts and feelings about the surgery. The nurse can then relay these concerns to the provider for further discussion if needed.)

A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? A. Encourage the client to verbalize questions. B. Insist the client take prescribed medications. C. Inform the client that the medication is the same as taken at home. D. Tell the client that refusal of the medication is considered noncompliance.

Encourage the client to verbalize questions. Rationale: The nurse acts as a client advocate by providing the client with information needed to make informed decisions regarding care.

A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? A. Euphoria B. Rhinorrhea C. Hallucinations D. Dilated pupils

Euphoria Rationale: Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? A. Assessing the current health status of the client B. Explaining the operative procedure, risks, and benefits C. Reviewing preoperative laboratory test results D. Ensuring that a signed surgical consent form was completed

Explaining the operative procedure, risks, and benefits Rationale:Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility.

Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. The charge nurse should recognize that which of the following is an appropriate approach to this conflict?

Explore alternative solutions to address unit workflow with the nurses (Exploring alternative solutions will allow the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution.)

a charge nurse recognized a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the charge nurse take first?

Explore the reasons that staff are not attending the meetings. (According to evidence-based practice, the nurse should first identify the reasons that staff are not attending the meetings. This allows the nurse to address the specific problems identified by the staff.)

A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following? A. Slander B. Invasion of privacy C. Defamation of character D. False imprisonment

False imprisonment Rationale: Unlawfully restraining a client is false imprisonment. Clients have the right to refuse treatment

A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with medication within 15 minutes. The nurse is demonstrating which of the following ethical principles?

Fidelity (The nurse is demonstrating fidelity by returning to the client's room with the medication in a timely manner. Fidelity is an ethical principle in which the nurse's actions are taken to display loyalty and keep a promise made to the client.)

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take? A. Focus on providing care that prevents life-threatening emergencies. B. Reinforce discharge teaching to clients. C. Instruct the assistive personnel (AP) to focus on clients' ADLs. D. Stock additional unit supplies.

Focus on providing care that prevents life-threatening emergencies. Rationale: The triage method in a disaster focuses on providing care to clients who have any immediate threat to life.

a charge nurse observes that a staff nurse's behavior has changed over the faw few weeks. Which of the following behaviors should the nurse identify as an indication that the staff nurse might be working while impaired?

Frequent use of restroom (Frequent use of the restroom can indicate that the nurse might be working while impaired. Other indications can include frequent errors, mood swings, inability to focus, and excessive wasting of controlled substances.)

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority? A. Gain 2 pounds of weight per week. B. Make positive statements about improvements in body image. C. Feel in control of her behavior. D. Identify changes within the family unit that promote the client's autonomy.

Gain 2 pounds of weight per week. Rationale: When using Maslow's hierarchy of needs, the nurse should determine the priority goal is to meet the physiological need for adequate nutrition. This means working with the client to attain an increase in weight of 2 to 3 pounds per week.

An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? A. Gather data about the nurse's work performance and attendance history. B. Approach the involved nurse to discuss the behavior. C. Notify the risk manager. D. Refer the nurse to the board of nursing diversion program.

Gather data about the nurse's work performance and attendance history. Rationale: The first action the nurse should take is to conduct an investigation and determine if the allegations are true.

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? A. Give positive feedback directly to the AP. B. Tell other nurses what an effective team member the AP is. C. Nominate the AP for the Employee of the Month award. D. Detail the AP's contributions to the nurse manager.

Give positive feedback directly to the AP. Rationale:Positive reinforcement is one of the most effective ways to recognize an employee's ability and to motivate the employee

a charge nurse is observing a newly licensed nurse's use of time-management skills. Which of the following actions by the newly licensed nurse indicated effective use of this skill?

Groups tasks that are in the same location (The newly licensed nurse should group tasks that are in the same location to effectively use time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills.)

A nurse is planning discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?

Home Health (A home health agency can provide nurses who will visit the home and help the guardian learn necessary skills, as well as assess the progress of the infant.)

an assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make?

I delegate tasks to personnel based on their job descriptions (This response addresses the AP's concerns and provides clear information about the charge nurse's responsibility when delegating tasks.)

A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following is an appropriate action of the charge nurse on the PACU?

Identify stable clients for transfer to a surgical unit (It is within the charge nurse's scope of practice to identify stable clients for transfer to a surgical unit. This action will enable the facility to do the most good for the greatest number of clients.)

A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict? A. Implement a resolution. B. Brainstorm solutions. C. Identify the problem. D. Evaluate the results.

Identify the problem. Rationale: The first action the nurse should take using the nursing process is to assess the situation and identify the problem so that a solution is found.

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

Inform the assistive personnel of the client's weight-bearing status. (Assistive personnel can assist clients with ambulation in most cases with appropriate delegation from the nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part of safe care delegation.)

A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? A. Vigorously rub the skin following a decontamination shower. B. Initiate seizure precautions. C. Provide respiratory support with a plastic oral airway. D. Prepare to administer amyl nitrate.

Initiate seizure precautions. Rationale: Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen.

At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN? A. Providing postmortem care for a client B. Measuring a client's I&O C. Obtaining a client's weight D. Inserting a nasogastric tube for a client

Inserting a nasogastric tube for a client Rationale: This is an appropriate task to assign to the LPN. It is not appropriate to assign this task to the AP.

a nurse is providing preoperative teaching for a client who is schedules for a total knee arthroplasty and speaks a different language than the nurse. Which of the following inter professional team members should the nurse include in the discussion?

Interpreter (The nurse should plan to request an interpreter for the client. The role of the interpreter is to interpret between the language spoken by the client and the language spoken by the nurse.)

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client's family is reached C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine

Invoking implied consent Rationale: The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? A. Keeping an appointment with a client B. Allowing a new mother to hold her stillborn infant C. Confirming that a client going for surgery has signed a consent form D. Refusing to disclose information about a client to the media

Keeping an appointment with a client Rationale: Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Perform wound irrigation for a client. B. Evaluate pain relief for a client following the administration of a pain medication. C. Measure and record intake and output for a client. D. Teach a client about low-sodium foods.

Measure and record intake and output for a client. Rationale: The AP can measure and record intake and output (I&O) for a client. It is the nurse's responsibility to review the recorded results and respond as necessary.

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)? A. Application of antibiotic ointment to the arm of a client who has dermatitis B. Obtaining medical history information from a stable client who is being admitted C. Monitoring vital signs of a client who had an appendectomy 12 hr ago D. Removal of the nasogastric tube of a client who has been receiving enteral feedings

Monitoring vital signs of a client who had an appendectomy 12 hr ago Rationale: Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an appropriate task for the AP because it does not involve assessment, specialized knowledge, or judgment.

A nurse on a medical-surgical unit has accepted a transfer to the intensive care unit (ICU). Prior to transfer to the ICU, the nurse completes an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence

Nonmaleficence Rationale: Nonmaleficence consists of actions taken to prevent client harm. When the nurse completes an advanced education program that will prepare her to provide safer care in the ICU, the nurse is demonstrating the ethical principle nonmaleficence.

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence

Nonmaleficence Rationale: Nonmaleficence, as a principle in research, is the obligation to do no harm to the client. Intentionally exposing clients to serious or permanent harm is unacceptable. Should such a situation emerge during the conduct of a study, the study should be terminated immediately.

A nurse is providing care for a surgeon on a medical surgical unit. A nurse from another unit asks the nurse about the surgeons medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principals? A. Utility B. Paternalism C. Justice D. Nonmaleficence

Nonmalefience Rationale: The nurse is obligated to protect the client's confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? A. Counsel the provider to determine the cause of the substance abuse. B. Encourage clients to change to a different provider. C. Inform the state medical board for an immediate investigation. D. Notify the nursing supervisor of the concerns.

Notify the nursing supervisor of the concerns. Rationale: The nurse should notify hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse.

A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take?

Notify the quality improvement team. (The nurse should report any unusual occurrences or trends, such as VAP within the unit, to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes.)

A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form? A. Extended family B. Blended family C. Nuclear family D. Intergenerational family

Nuclear family Rationale: A nuclear family consists of parents and offspring.

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? A. Members of the Federal Emergency Management Agency (FEMA) B. Responding law enforcement officers C. Representatives from the American Red Cross D. Nurses and other emergency medical personnel

Nurses and other emergency medical personnel Rationale: Nurses and other emergency personnel such as physicians, EMTs, and paramedics are responsible for performing triage duties.

a nurse is caring for a client who report vomiting and diarrhea for the past 6 hr. The nurse should identify that which of the following assessments is the priority?

Obtain the client's serum potassium level. (Because vomiting and diarrhea contribute to the loss of potassium through body fluids, the greatest risk to this client is life-threatening cardiac dysrhythmias as a result of hypokalemia; therefore, the nurse should identify that the priority assessment is the client's serum potassium level.)

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? A. Change the abdominal dressing. B. Obtain vital signs. C. Palpate for possible bladder distention. D. Observe the incision site

Obtain vital signs. Rationale: Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.

A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning her clothes. Which of the following referrals should the nurse recommend for the client?

Occupational therapist (The nurse should recommend a referral to an occupational therapist for a client who has osteoarthritis and reports difficulty with ADLs, such as buttoning clothing. Occupational therapy can assist the client with exercises to help the client complete these tasks.)

A nurse is observing a newly licensed nurse perform a sterile dressing charge on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Picks up first sterile glove by grasping the folded cuff edge (The nurse should pick up the first sterile glove by grasping the folded cuff edge, which is the palmar side, to prevent contamination of the outside of the glove.)

A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching?

Place clients in positive-pressure airflow rooms. (The nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour.)

a charge nurse is preparing to observe a newly licensed nurse performa routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?

Place the client in a dorsal recumbent position for the examination. (To prepare the client for a routine abdominal assessment, the nurse should place the client in a dorsal recumbent or supine position and ensure that the client relaxes her abdominal muscles.)

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse? A. BUN 15 mg/dL B. Platelet count 60,000/mm3 C. WBC 6,000/mm3 D. Hemoglobin 14 g/dL

Platelet count 60,000/mm3 Rationale: This platelet count is below the expected reference range. A low platelet count places the client at risk for bleeding; therefore, the nurse should follow up on this finding

A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first see the client who has which of the following laboratory values?

Platelets 100,000/mm3 (A client who has a platelet count of 100,000/mm3 is unstable because this value is below the expected reference range of 150,000 to 400,000/mm3, which places the client at risk for bleeding; therefore, the nurse should visit this client first.)

A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take? A. Assess the AP's ability to follow the client's teaching plan. B. Determine the social skills of the AP. C. Evaluate the ability of the AP to work with peers. D. Provide a clear description of the task to the AP.

Provide a clear description of the task to the AP. Rationale:Providing a clear, concise description of the task, as well as the expected outcome, is essential when planning to delegate a task to the AP

a charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

Provide an enteral feeding to a client who has Crohn's disease. (Administration of an enteral feeding is within the scope of practice of an LPN; therefore, it is appropriate for the charge nurse to assign this task to an LPN.)

a hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse including in the plan of care?

Provide the client with information about advance directives. (Health care providers must offer information to clients regarding their rights to make decisions about their care.)

A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take? A. Inform the staff member of her appraisal time for that day prior to change-of-shift report. B. Schedule the appraisal interview as early in the shift as possible. C. Provide a chair directly across the desk for the staff member to sit in. D. Provide the staff member with a copy of the appraisal form in advance.

Provide the staff member with a copy of the appraisal form in advance. Rationale: The charge nurse should ensure the staff member knows the standards by which her work will be evaluated and that she has a copy of the appraisal form.

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take? A. Pull the curtain around the client's bed. B. Wash the client's arms and hands first. C. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus. D. Fill the bath basin with tap water that is 39° C (102.2° F).

Pull the curtain around the client's bed. Rationale: The nurse should close the door to the client's room and pull the curtain around the client's bed to ensure the client's right to privacy.

A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit? A. Availability of resources, such as fire extinguishers B. Nursing staff ratios C. Quality of nursing care provided D. Length of facility stay for a cohort of clients

Quality of nursing care provided Rationale: Process audits evaluate the quality of care nurses provide. They also determine if the care provided by nurses is consistent with established facility policy.

A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? A. Quietly tell the APs that this is not appropriate. B. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. C. Complete an incident report. D. Document the occurrence in a personal log.

Quietly tell the APs that this is not appropriate. Rationale: The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents? A. Chemical B. Anthrax C. Radiologic D. Sarin

Radiologic Rationale:A "dirty bomb" combines radiologic agents with an explosive device, resulting in immediate effects of radiation exposure.

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include?

Raise the footplates of the wheelchair before transferring the client. (The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury.)

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? A. Wound drainage for culture B. Urine from an indwelling catheter C. Blood for PaCO2 D. Random stool specimen

Random stool specimen Rationale: The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required

A nurse on a medical-surgical unit is caring for a client transferring from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Receiving moderate sedation (The nurse should verify that the client has given informed consent prior to receiving moderate sedation because this involves anesthesia.)

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN? A. Complete an admission assessment for a client who has COPD. B. Measure I&O for a client who has an indwelling urinary catheter. C. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. D. Develop a plan of care for a client who has cholecystitis.

Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. Rationale: Reinforcing teaching with a client is within the scope of practice of a LPN; therefore, the RN should delegate this task to the LPN.

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Remind the staff members that this is a breach of confidentiality. (When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality.)

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse? A. Transporting a client who experienced a stroke 72 hr ago to the radiology department B. Providing a back rub to a client who has right-sided paralysis C. Removing and cleaning the cannula of a client who has a new tracheostomy D. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm

Removing and cleaning the cannula of a client who has a new tracheostomy Rationale: Removing and cleaning the cannula of a client who has a new tracheostomy requires use of the nursing process, specialized knowledge, and clinical judgment; therefore, this task should be reassigned to a licensed nurse.

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps in order) A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire. D. Rescue the clients.

Rescue Clients Pull Fire Alarm Confine the Fire Extinguish the Fire

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? A. Hospice care B. Restorative care C. Mental health care D. Respite care

Respite care Rationale: Respite care provides temporary relief for caregivers who care for disabled or chronically ill clients. The respite allows the caregiver an opportunity to complete errands and personal business, as well as time to recover both emotionally and physically.

A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take?

Review the client's request with the family. (The client's living will states that artificial enteral feedings should not be allowed, and the nurse should review the client's request with the family. Staff members should use the client's living will as the guide for treatment unless a durable power of attorney for health care has been created.)

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement? A. Sit in front of the group for the meeting and then stand for the announcement. B. Cross her arms over her chest when beginning the announcement. C. Stare at the people the announcement will affect the most. D. Lean gently over the back of a chair sitting to one side of the room when making the announcement.

Sit in front of the group for the meeting and then stand for the announcement. Rationale: The weight of a message increases when the sender stands.

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which legal resource should the nurse consult in planning for this policy?

State Nurse Practice Act (NPA) (The nurse should consult the NPA in this situation because the NPA defines the scope and boundaries of professional nursing practice. The NPA provides guidelines for developing standardized procedures within specific facilities where expanded nursing functions have been approved in collaboration with nurses, providers, and administration.)

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN

State Nurse Practice Act for the LPN Rationale: According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation.

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? A. Make a copy of the incident report for the provider. B. Submit the incident report to the risk manager. C. Place the incident report in the client's chart. D. Document in the chart that an incidence report has been filed.

Submit the incident report to the risk manager. Rationale: The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? A. Take an arterial blood gas (ABG) specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. C. Pass fresh water to clients on the unit. D. Obtain a routine urine sample from a newly-admitted client.

Take an arterial blood gas (ABG) specimen to the laboratory. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.

A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take? A. Review the LPN's personnel file. B. Discuss the LPN's behavior with other nurses on the unit. C. Talk with the clients who have reported the LPN's lack of care. D. Reassign some of the LPN's client care to assistive personnel.

Talk with the clients who have reported the LPN's lack of care. Rationale: The charge nurse should investigate the allegations of misconduct to determine if disciplinary action is warranted.

A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first? A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. B. Report the behavior to the nurse manager. C. Create a written document of the incident and store the document in a safe place. D. Seek help from a trustworthy friend.

Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. Rationale: Sexual harassment is unwanted sexual advances made in the context of a relationship of unequal power or authority. It is experienced as offensive in nature. The nurse should first start by taking the most direct measure: confronting the hiring manager and insisting the harassment stop.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? A. The AP's ability to prioritize B. The AP has the knowledge and skill to perform the task C. The AP's rapport with clients D. The AP's ability to complete the task without assistance

The AP has the knowledge and skill to perform the task Rationale: The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.

a nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

The child has red fissures at the corners of the mouth. (Using Maslow's hierarchy of needs, the nurse should determine that the priority finding is red fissures at the corners of the child's mouth. This can indicate a vitamin B deficiency, which is a physiological need.)

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? A. The client's partner B. The client C. The client's daughter, who is the primary caregiver D. The client's son, who has a durable power of attorney

The client Rationale: If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the confrence?

The client refuses to attend physical therapy sessions. (The greatest risk to this client is postoperative complications due to immobility, such as atelectasis or pneumonia; therefore, the priority for discussion is the client's refusal to participate in physical therapy.)

a nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicated the client the nurse should assess first?

The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void. (Not voiding for 6 to 8 hr after indwelling urinary catheter removal indicates this client is at risk for urinary retention, which can cause a urinary tract infection. Overdistention of the bladder can cause damage to the mucosa. Therefore, the nurse should assess this client first and report findings to the provider.)

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? A. The client who requires frequent ambulation B. The client who is in protective isolation C. The client who is actively dying and requires IV pain medication D. The client who is 3 days postoperative and requires a dressing change

The client who is actively dying and requires IV pain medication Rationale: The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.

A nurse is caring for a client who is 3 days postoperative following open heart surgery and is to transfer to the medical-surgical unit. Which of the following should the nurse plan to include in the verbal report?

The client's level of consciousness (The nurse should include objective data regarding the client's current consciousness status in the verbal report.)

A nurse is reviwing a clients pathway upon discharge follwoing hip arthroplasty. Which of the following infromation can assist the nurse in evaluating the cost effectiveness of the care?

The length of the client's stay (The client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten the length of stay.)

A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? A. The nurse uses clean gloves when discontinuing a client's intravenous infusion. B. The nurse empties a client's drainable colostomy pouch when it is one-third full. C. The nurse uses the client's telephone number as one form of identification when administering medications to a client. D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.

The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. Rationale: The nurse should avoid reaching across a sterile field; therefore, the nurse should place the sterile tray on the work surface so the top flap opens away from the body.

A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the nurse identify as demonstrating sterile technique?

The nurse places the sterile package with the top flap opening away from the body. (The nurse should place the sterile package on a flat surface so that the top flap opens away from the body. This prevents the contents of the sterile package from becoming contaminated.)

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? A. The nurse separates the client's labia with her dominant hand. B. The nurse coats the indwelling urinary catheter with lubricant. C. The nurse provides perineal care prior to inserting the urinary catheter. D. The nurse applies the sterile drape prior to inserting the urinary catheter.

The nurse separates the client's labia with her dominant hand. Rationale: The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider? A. The most experienced nurse receives the more complex clients B. Personal comfort level in making the assignments C. Social relationships between nurses working the oncoming shift D. The physiologic status of the clients on the unit

The physiologic status of the clients on the unit Rationale: Making assignments requires knowing the physiologic status of the clients on the unit, such as the stability of the clients' vital signs, the amount of health education they need, and the complexity of care involved. Clients who have an unstable physiologic status may require a higher level of skilled care.

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. B. The purpose of medication reconciliation is to prevent adverse medication reactions. C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.

The purpose of medication reconciliation is to prevent adverse medication reactions Rationale: Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN? A. The state Nurse Practice Act B. The National Association for Practical Nurse Education and Services C. The National Council of State Boards of Nursing Decision Tree D. The Omnibus Budget Reconciliation Act of 1987

The state Nurse Practice Act Rationale: The state Nurse Practice Act identifies the skill or education level needed by a nurse to complete a task, as well as indicating items that can and cannot be delegated from a legal perspective.

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? A. Preventing cross-contamination of clients B. Performing concise client assessment C. Transferring a client to the discharge location D. Maintaining a client tracking system

Transferring a client to the discharge location Rationale: Nursing care in a disaster setting focuses on essential care. The nurse should recognize nonskilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel.

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? A. Transporting a school-age client who is in traction to another department B. Playing a computer video game with an adolescent who has sickle cell disease C. Reading a book to a preschool client who has AIDS D. Rocking an infant who was admitted for croup

Transporting a school-age client who is in traction to another department Rationale: To ensure client safety, the nurse is responsible for delegating tasks to the right people. The nurse should avoid assigning this task to the volunteer because the individual who performs this task must understand the principles of traction. A volunteer does not have the requisite skill to perform this task.

A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take? A. Change the client's dressing. B. Reassign the task to another nurse. C. Verify the LPN knows how to do a dressing change. D. Report the issue to the unit manager.

Verify the LPN knows how to do a dressing change. Rationale: The charge nurse should attempt to see the delegated task from the perspective of the individual being delegated to. This approach clarifies the reason for lack of action by the LPN.

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Wash the site of injury with soap and water.

a charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?

Wear an N95 respirator mask when in the client's room. (The nurse should wear an N95 respirator mask when caring for clients who have suspected pulmonary tuberculosis.)

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? A. Discussing advance directives with the client and the client's family B. Providing comfort care measures to the client C. Withholding a dose of narcotic pain medication when the client has respiratory depression D. Allowing the client's family unlimited visitation at the time of death

Withholding a dose of narcotic pain medication when the client has respiratory depression Rationale: The principle of nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence.

A nurse is caring for a client who has a terminal illness and voices concern about performing care after discharge. Which of the following statements should the nurse make?

Your case manager will coordinate the resources you will need. (A case manager coordinates a client's care, including resources for home care.)

A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take? A. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. B. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. C. Explain the risk the client faces if she leaves the facility. D. Ask the security department to guard the room to the client's door.

explain the risk the client faces if she leaves the facility Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3. The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.

An Assistive personal (AP) a nurse on the unit tells the nurse that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first?

gather data about the nurses work performance and attendance history

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused

observing a postoperative client who is confused Rationale: A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?

perform a chart review to gather data about the clients who developed infections (The first action the nurse manager should take when using the nursing process is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection.)

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? A. Provide an inservice on medication administration to all the nurses. B. Require staff nurses to demonstrate competency by passing a medication administration examination. C. Review the events leading up to each medication administration error. D. Develop a quality improvement program for nurses involved in medication administration errors.

review the events leading up to each medication administration error Rationale:After a sentinel event, the first step the committee should plan to take is to use root cause analysis to identify the underlying cause or causes that led to the medication errors.