ATI_AQ-Leadership_and_Management

A nurse is preparing to administer a client's anticoagulant medication. The client states, "I don't like taking this medication. I always have to get my blood checked." Which of the following responses should the nurse make? A. "You can refuse the medication. I will notify your provider." B. "This medication is given at all times to clients, and they don't have a problem." C. "I will come back later to give you the medication." D. "You need to take this medication in order to feel better."

"You can refuse the medication. I will notify your provider." *The nurse should act as an advocate for the client and acknowledge that the client has the right to refuse any medication or treatment offered. The nurse should inform the provider of the client's decision

A charge nurse is assisting with teaching a group of clients in an assisted-living facility about clients' rights. Which of the following pieces of information should the charge nurse include in the teaching? A. "You can request to review your personal medical records at any time." B. "A 20-day notice is required prior to you being transferred to long-term care." C. "An executor will be assigned to manage your financial affairs." D. "You will have a provider assigned to your care other than your primary provider."

"You can request to review your personal medical records at any time." *Clients have the right to request their own medical records and should expect adequate and appropriate care from the facility's personnel

A nurse is reinforcing discharge teaching with a client who has a leg wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following pieces of information should the nurse include in the teaching? (select all that apply) A. Use cotton balls to clean the infected areas B. Cleanse the wound with tap water C. Dry the leg wound after cleaning D. Microwave the cleaning solution before applying to the wound E. Discard soiled bandages in a moisture-proof bag

1. Cleanse the wound with tap water 2. Discard soiled bandages in a moisture-proof bag *Tap water or 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages and gloves should be placed in double-bagged moisture-proof bags and not in the regular trash to avoid spreading contamination to other family members within the household

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse attend to first? A. A client who is receiving metoclopramide and reports diarrhea B. A client who is receiving tamsulosin and reports feeling dizzy C. A client who is receiving cephalexin and reports dyspnea D. A client who is receiving erythromycin and reports epigastric pain

A client who is receiving cephalexin and reports dyspnea *The greatest risk to this client is an injury from dyspnea due to an allergic reaction from the antibiotic. The client is at risk for anaphylactic shock with a compromised airway; therefore, the first action the nurse should take is to discontinue the cephalexin and notify the provider immediately. Emergency equipment should be placed in the client's room in case the client goes into anaphylactic shock

A nurse is caring for a client who is undergoing the repair of an abdominal aortic aneurysm. After the surgery and immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the client's ongoing and specific needs for care? A. Charge nurse B. Case manager C. Vascular surgeon D. Home health care nurse

Case manager *The case manager will plan and coordinate resources and services to help meet the client's needs over the entire continuum of care

A nurse is reviewing the medication administration record for a client and notes that the nurse from the previous shift gave double the dose of antihypertensive medication prescribed to the client. Which of the following actions should the nurse perform first? A. File an incident report with factual information about the error B. Report the incident to the nursing supervisor C. Check on the client's condition D. Notify the client's provider about the incident

Check on the client's condition *The greatest risk to this client is an injury from low blood pressure due to a double dose of antihypertensive medication. Therefore, the first action the nurse should take is to check on the client's condition and obtain the client's vital signs, including blood pressure

A nurse enters a client's room and finds the client lying on the floor next to the bed. Which of the following actions should the nurse take first? A. Determine the cause of the incident B. Check the client for injuries C. Call for assistance to get the client back in bed D. Complete an incident report

Check the client for injuries *The first action the nurse should take when using the nursing process is to collect data from the client. The nurse should determine whether the client has sustained any injuries from the fall and implement interventions to ensure the client's safety and wellbeing

A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. The nurse places the client's medications on the left side of his mouth and administered the pills individually. Which of the following ethical principles is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice

Nonmaleficence *Nonmaleficence is the duty to do no harm and to protect clients from harm by eliminating threats. These actions are important for promoting the safety of the client by preventing aspiration

A nurse is reinforcing teaching about a living will who has end-stage breast cancer. Which of the following pieces of information should the nurse include in the teaching? A. The client has the right to change the living will at any time B. The client should be certain of her living will because the document establishes guidelines that refuse medication C. A durable power of attorney for health care is required with a living will D. The handwritten living will is not a legal document and cannot be included in the client's medical record

The client has the right to change the living will at any time *A living will is a component of advance directives. This legal document expresses the client's wishes regarding health care decisions in the event the client becomes incapacitated or is unable to make decisions. The client has the right to change or revoke the living will at any time

A charge nurse is providing teaching to a new staff nurse regarding delegation to assistive personnel (AP). Which of the following pieces of information should the charge nurse include in the teaching? A. The nurse can delegate the task of teaching a client about foot care to the AP B. The nurse should be familiar with the task he/she plans to delegate C. The person who accepts the delegated task also assumes accountability for the task D. The AP should report to the nurse any tasks that he/she further delegates to other APs

The nurse should be familiar with the task he/she plans to delegate The nurse should be familiar with the task he/she plans to delegate in order to define the task and expectation of its completed status, monitor the performance of the task, and provide feedback regarding the performace

A nurse overhears 2 nurses discussing a conflict they are having about who should complete certain client-care tasks. The nurses agree that they are tired of the conflict and will let the nurse manger decide who should complete the tasks. The nurse should identify this outcome as which of the following approaches to conflict management? A. Win-win B. Win-lose C. Win-yield D. Lose-Lose

Win-yield *A win-yield approach involves both parties no longer trying to resolve the conflict. they take no initiative to end the conflict and agree to honor whatever the nurse manager decides

A nurse in a mental health clinic is interviewing a client who has a history of substance use disorder. The client reports his experiences from a previous voluntary hospitalization. Which of the following reported experiences constitutes assault? A. "I was threatened with a shot when I refused to take an oral medication I knew would make me groggy." B. "I was held down against my will so the staff could administer a shot." C. "I was told I had to stay in the facility despite asking to leave." D. "I was exposed as a substance abuser to other clients in a group session."

"I was threatened with a shot when I refused to take an oral medication I knew would make me groggy." *Threatening to medicate the client against his wishes is assault. The tort of assault occurs when a person puts another in fear of consensual contact

A nurse is assisting with the admission of a client who has measles. The nurse should identify that this client should be placed in which of the following types of isolation? A. Airborne B. Contact C. Droplet D. Protective environment

Airborne *The nurse should place this client who has measles in airborne isolation. Airborne isolation is used for clients who have infections that can be transmitted through droplets in the air that are smaller than 4 microns. Therefore, the nurse should place the client in a private room that has a negative-pressure airflow with at least 6 to 12 exchanges per hour. The nurse should also wear an N95 respirator mask while caring for the client

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements regarding the purpose of a critical pathway should the nurse plan to include? A. "A critical pathway is a plan of care that is specific to the nursing interventions necessary for client care." B. "A critical pathway is a tool that legally binds the health care facility to provide services as outline." C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." D. "A critical pathway is a plan that might be the same for several diagnoses that are similar to each another."

"A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." *A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired client outcomes and an appropriate length of stay for the particular diagnosis

A nurse is talking with a family member who is unhappy with the care being delivered to his parent. Which of the following responses should the nurse provide? A. "Can you give me a specific example of care that caused dissatisfaction?" B. "The client has a lot of complex medical conditions." C. "We'll talk later when you have calmed down." D. "We are very busy with all the clients on this unit."

"Can you give me a specific example of care that caused dissatisfaction?" *Requesting an example of a specified event can allow the nurse to view the family member's comments objectively and address his concerns

A nurse is caring for a client who asks, "Is the client in the next room in pain? I hear her cry out frequently." Which of the following responses should the nurse make? A. "That client has cancer and is quite comfortable." B. "We are doing our best to keep that client as comfortable as possible." C. "Does the crying out bother you?" D. "Why don't you ask that client's family members when they visit?"

"Does the crying out bother you?" *This therapeutic response focuses on the client's feelings rather than on confidential information concerning the client in the next room. It summarizes the client's query and asks an open-ended relevant question for the client to expand upon his concerns

A nurse is interviewing a client who has a new diagnosis of major depression. Which of the following questions is the nurse's priority? A. "Have you thought about hurting yourself?" B. "What has been troubling you?" C. "Do you have anyone who can offer your support?" D. "When did you start to feel badly?"

"Have you thought about hurting yourself?" *When using the greatest risk approach to client care, the nurse should identify that this client is at risk of suicide. Therefore, the priority question the nurse should ask is whether the client has had thoughts of self-harm or suicide

A nurse is caring for an adult client who is scheduled for a procedure. The client's son asks the nurse what medication is being given to the client. Which of the following responses should the nurse make A. "I am sorry, but you'll need to ask your father for that information." B. "Your father was given lorazepam to treat anxiety. C. "You will need to ask the charge nurse for that information." D. "Don't worry. We will give your father all pertinent information before discharge."

"I am sorry, but you'll need to ask your father for that information." *The nurse must keep the client's personal health information confidential. The client may choose to share confidential information with his son

A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client states, "I don't think I can go through with the surgery after all." Which of the following responses should the nurse offer? A. "I will let your surgeon know about your decision." B. "I recommend that you have the surgery so you don't require as much chemotherapy." C. "If you don't have the surgery, you will likely die from breast cancer." D. "If you are worried about your body image, that will pass with time."

"I will let your surgeon know about your decision." *The nurse should notify the client's surgeon about the decision she has made regarding the procedure. The nurse must be the client's advocate and respect the client's wishes. The client has the right to refuse or change her mind at any time regarding the treatment offered.

A nurse is caring for a client with a history of severe multiple sclerosis and asks the nurse about completing a living will. Which of the following statements should the nurse make? A. "I will provide the information you need to complete advance directives." B. "I will report your desire to complete a living will to the provider." C. "You attorney will need to review the document before it can be enacted." D. "Once your living will is complete and on file, the choices you make are final."

"I will provide the information you need to complete advance directives." *Under the Patient Self-Determination Act, health care institutions are required to provide educational materials advising clients of their rights to make their personal wishes known regarding treatment

A 13-year-old female adolescent tells the charge nurse in the pediatric unit that she does not want a male nurse assigned to care for her. Which of the following responses should the nurse make? A. "I will need to discuss your request with your parents first." B. "I'll change the assignment so a female nurse is caring for you today." C. "A female assistive personnel (AP) will be assisting you with your bath." D. "The male nurse assigned to care for you is required to care for both male and female clients."

"I'll change the assignment so a female nurse is caring for you today." *The client has the right to respect and personal dignity and the ability to participate in decisions regarding her care. The charge nurse should change the assignment when possible to minimize feelings of loss and control for this client

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

"Let me call your surgeon while you tell me about your concerns." *The client has the right to refuse treatment. Speaking with the nurse and the provider about concerns or questions might relieve anxieties and allow the client to continue with the procedure. Consent may be withdrawn after being given, and clients have the right to change their minds. It is the nurse's responsibility to notify the surgeon if the client verbalizes a desire to stop or delay a medical procedure or treatment

A nurse is reinforcing teaching with a client about organ donation. Which of the following statements by the client indicates an understanding of the teaching? A. "People age 18 and over have the right to make an organ donation." B. "I have to make organ donation a provision in my will." C. "Once I make the decision to donate, I cannot change that decision." D. "A family member has to serve as a witness for me to be an organ donor."

"People age 18 and over have the right to make an organ donation." *Under the Uniform Anatomical Gift Act, individuals must be at least 18 years or older to make an anatomical gift

A nurse is assisting with the plan of care for a client who has heart failure and lives alone. A referral has been made for a case manager to visit with the client. Which of the following explanations should the nurse give the client about the role of a case manager? A. "The case manager will provide direct care for the remainder of your stay in the hospital." B. "The case manager will coordinate and plan your care while you recover from your surgery." C. "The case manager will meet with you the day before your scheduled discharge date." D. "The case manager is responsible for completing your insurance claim forms."

"The case manager will coordinate and plan your care while you recover from your surgery." *The role of the case manager is to coordinate and plan client care, collaborate with other health professionals, and monitor costs and quality of care

A charge nurse is performing a quality-assurance audit on the documentation of several client's charts. Which of the following documentation items should the charge nurse identify as a correct entry in the client's medical record? A. "The client appeared angry when family members were visiting." B. "The client ambulated for 10 min, 3 times during the shift." C. "The client seemed to be upset about the diagnosis." D. "An incident report was completed when the client fell at 1000."

"The client ambulated for 10 min, 3 times during the shift." *This documentation item reflects objective data about the client's actions

Nurses working in a long-term care facility inform the nurse manager that the whirlpool bath unit need to be updated in order to make client bathing more efficient. Which of the following responses should the nurse manager provide? A. "This purchase will require the completion of a variance analysis." B. "This purchase will need to be addressed in the capital budget plan for the unit." C. "This purchase will result in a reduction in the operating budget." D. "This purchase can be reimbursed by Medicare funds since clients who use Medicare will benefit from the equipment."

"This purchase will need to be addressed in the capital budget plan for the unit." *The capital budget plans for the expenditure of money for equipment and major purchases that have a long life of use

A nurse is caring for a client who has breast cancer and is scheduled to have a mastectomy. The client tells the nurse she is concerned about how her partner will react to the procedure. Which of the following responses should the nurse provide? A. "I will inform your surgeon that you are having second thoughts." B. "I think you should postpone the surgery until you are certain you want to have it." C. "Would you like me to have a member of a breast cancer support group visit with you?" D. "This is a common concern of women undergoing a mastectomy."

"Would you like me to have a member of a breast cancer support group visit with you?" *The nurse should serve as an advocate for this client. Offering to have a member of a breast cancer support group visit allows the client to speak with someone who has been through the same experiences and can assist with emotional aspects of having a mastecomy.

A nurse suspects that a coworker is coming to shifts under the influence of alcohol. Which of the following behaviors in the workplace are consistent with substance use disorder? (Select all that apply) A. Extended lunch periods and breaks B. Calling in sick frequently on Mondays or Fridays C. Expressing frustration with work assignments D. Decreased concern regarding personal appearance and grooming E. Excessive use of cologne or mouthwash

1. Extended lunch periods and breaks 2. Calling in sick frequently on Mondays or Fridays 3. Decreased concern regarding personal appearance and grooming 4. Excessive use of cologne or mouthwash *Extended lunch periods and breaks might indicate that the individual is ingesting alcohol in a remote location. Calling in sick frequently on Mondays or Fridays might indicate that the individual is binge drinking on weekends and is too ill to come to work. A decrease in concern about personal appearance and grooming is another sign of substance use disorder. Finally, excessive use of cologne or mouthwash may indicate that the individual is attempting to cover up the smell of alcohol

A nurse on a pediatric unit is assisting with preparing a list of clients for potential discharge to home due to a local incident involving multiple children. Which of the following clients should the nurse place on the potential discharge list? (select all that apply) A. A preschooler with asthma who has scattered wheezes that resolve with PRN use of albuterol B. A school-aged child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics D. A toddler with a ventricular septal defect and bronchiolitis who is on 28% oxygen by oxyhood E. An adolescent client who is 1 day postoperative following scoliosis repair and is on a PCA pump

1. A preschooler with asthma who has scattered wheezes that resolve with PRN use of albuterol 2. A school-aged child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine 3. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics *The nurse should place clients who can be quickly and safely discharged on the potential discharge list. Children who have asthma can be managed at home once the acute phase of illness has resolved. Because this preschooler's manifestations are responsive to the prescribed medication, this child can be safely discharged home with appropriate discharge teaching and if follow-up care is planned. External fixation devices are worn for weeks to months; they are most often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This school-aged client's pain is responsive to oral codeine. Prior to discharge, the client might need instructions on ambulation and weight-bearing as prescribed. Finally, long term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse an assist this client in home care management. The client's developmental delay has no bearing on whether the client is safe to discharge

A charge nurse is preparing a departmental in-service session about radioactive implants for a group of staff nurses. Which of the following pieces of information should the charge nurse include in the presentations? (select all that apply) A. Clients should be placed in a private room B. Throw away an implant that has fallen out in the client's trash can C. Staff should wear a dosimeter badge when caring for the client D. Clients should be on bed rest E. Children over the age of 12 years can visit clients if they are accompanied by an adult

1. Clients should be placed in a private room 2. Staff should wear a dosimeter badge when caring for the client 3. Clients should be on bed rest *Clients should be placed in a private room to avoid exposing other clients to radiation from the implant. The nurse should follow the principles of time, distance, and shielding when working with a client who is receiving internal radiation therapy. Health care providers should wear a dosimeter badge while caring for a client who has a radioactive implant; this badge measures and records a staff member's amount of exposure to radiation. Clients who have a radioactive implant should remain on bed rest while the implant is in place to prevent dislodgement

A nurse is caring for a group of client on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply) A. Collecting a stool specimen B. Providing instructions about using a spirometer C. Measuring oral intake D. Providing postmortem care E. Changing a sterile dressing

1. Collecting a stool specimen 2. Measuring oral intake 3. Providing postmortem care *The nurse should delegate collecting a stool specimen, measuring oral intake, and providing postmortem care to the assistive personnel (AP) because these tasks do not require assessment, analysis, or teaching and are within the range of function for an AP

A nurse manager is evaluating the time-management strategies of a newly licensed nurse. Which of the following actions taken by the nurse are effective time-management strategies? (Select all that apply) A. Completing a task before beginning another task B. Documenting client care at the end of the shift C. Taking time to plan care at the beginning of the shift D. Completing the more time-consuming tasks at the end of the shift E. Mentally visualizing a procedure prior to gathering equipment

1. Completing a task before beginning another task 2. Taking time to plan care at the beginning of the shift 3. Mentally visualizing a procedure prior to gathering equipment *Completing a task before beginning another task is an effective time-management strategy the newly licensed nurse should use. A nurse who goes from task to task rarely completes responsibilities effectively or in a timely manner. Taking time to plan care at the beginning of the shift allows effective daily planning, which is important for managing and prioritizing tasks. Mentally visualizing a procedure prior to obtaining equipment helps the newly licensed nurse avoid making unnecessary trips back to the supply room for equipment

A nurse is preparing to insert an indwelling urinary catheter for a female client. The nurse has performed hand hygiene, positioned the client, opened and organized the equipment, and donned sterile gloves. In which order should the nurse implement the remaining actions? A. Insert the catheter B. Inflate the retention balloon C. Lubricate the catheter's tip D. Collect a urine specimen E. Cleanse the meatus

1. Lubricate the catheter's tip 2. Cleanse the meatus 3. Insert the catheter 4. Inflate the retention balloon 5. Collect a urine specimen

A charge nurse on a medical-surgical unit is assigning client care for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply) A. Performing colostomy care B. Measuring a client's intake and output C. Interpreting a client's values following surgery D. Providing postmortem care to a client E. Check nasogastric tube patency

1. Measuring a client's intake and output 2. Providing postmortem care to a client *Measuring a client's intake and output and providing postmortem care are within the range of function for an assistive personnel (AP)

A charge nurse is preparing for an in-service session about client advocacy for a group of staff nurses. Which of the following situations should the nurse include as an example of client advocacy? (select all that apply) A. Discussing treatment options with a client who was diagnosed with pancreatic cancer B. Notifying the provider when a client has questions about the procedure C. Helping a client make a list of questions she would like to ask the provider D. Clarifying the dosage of a medication prescribed for a client who has impaired liver function E. Carrying out the end-of-life wishes outlined in the living will of an older client who has end-stage renal disease

1. Notifying the provider when a client has questions about the procedure 2. Helping a client make a list of questions she would like to ask the provider 3. Clarifying the dosage of a medication prescribed for a client who has impaired liver function 4. Carrying out the end-of-life wishes outlined in the living will of an older client who has end-stage renal disease *as an advocate, the nurse should make sure clients have all their questions answered and possess the information needed to make an informed decision. Clarifying the dosage of a medication prescribed for a client can prevent medication toxicity and demonstrates client advocacy. Finally, carrying out the end-of-life wishes of a client who has end-stage renal disease also demonstrates client advocacy

A nurse in a medical-surgical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? A. A newly admitted client who is scheduled to have an indwelling urinary catheter inserted B. A client who has kidney stones and reports flank pain of 6 on a scale of 0 to 10 C. A client diagnosed with early stage chronic kidney disease who has a serum creatinine level of 2.0 mg/dL D. A client who has a cast newly applied on the forearm and reports tingling of the fingers

A client who has a cast newly applied on the forearm and reports tingling of the fingers *The first action the nurse should take when using the ABC approach to client care is to collect data from the client who has a newly applied cast on the forearm and reports tingling of the fingers. Tingling, numbness, pallor, paresthesia, and pain are clinical manifestations associated with compartment syndrome, a serious complication in which tissue pressure in a confined anatomical space reduces blood flow, leading to ischemia, dysfunction, and eventual necrosis. The nurse should report this finding to the provider immediately

A charge nurse on a medical-surgical unit is making client assignments for the oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who requires an update to the plan of care following a diagnosis of cancer B. A client who is postoperative following a total hip replacement and requires discharge teaching C. A client who has a prescription for irrigation of an indwelling urinary catheter D. A client who just arrived from PACU and requires a head-to-toe assessment

A client who has a prescription for irrigation of an indwelling urinary catheter *It is within the scope of practice of an LPN to irrigate an indwelling urinary catheter when prescribed by a provider

A nurse is preparing to care for a group of clients after receiving a change-of-shift report. From which of the following clients should the nurse collect data first? A. A client who has benign prostate hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

A client who has emphysema and reports dyspnea *ABC priority, therefore the nurse should first collect data from the client who has emphysema and reports dyspnea

A nurse is contributing to the plan of care for several clients. Which of the following clients should the nurse refer to a case manager? A. A client who has neurological deficits following a stroke B. A married female client who just delivered a full-term newborn C. A client who is postoperative following a cholecystectomy D. A child who has a fracture of the dominant arm

A client who has neurological deficits following a stroke *The nurse should refer this client to the case manager for care. A client who had a stroke will likely require long-term treatment. A client who has ongoing needs for care of rehabilitation should receive care that is directed by a case manager due to the complexity and cost of these needs

A nurse is reinforcing teaching with a newly hired nurse about violations of client rights. Which of the following should the nurse include as an example of a violation of client rights? A.A client who is confused and recovering from abdominal trauma has mitten restraints placed to prevent disruption of an abdominal wound B. A health care proxy releases the medical records of a client to a long-term care facility for placement evaluation C. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex D. The parents of a 16-year-old client who has gunshot wounds decide to limit their child's visitors to family

A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex *Seclusion is a restraint that should be used when a client is demonstrating violent or self-destructive behavior that jeopardizes the safety of self or others. This client does not meet the criteria for seclusion

A nurse is selecting clients for discharge following an environmental disaster. Which of the following clients should the nurse expect? A. A client who had a cast removal due to compartment syndrome B. A client who is scheduled for dialysis and has a potassium level of 6.2 mEq/L C. A client who has type 1 diabetes mellitus and a blood glucose of 320 mg/dL D. A client who is 1 day postoperative following an inguinal hernia repair

A client who is 1 day postoperative following an inguinal hernia repair *The nurse should select a client who has inguinal hernia repair for discharge because this client is stable

A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first? A.A client who requires a sterile dressing change B. A client who requires a gastrostomy tube feeding C. A client who requires urinary catheter care D. A client who requires endotracheal suctioning

A client who requires endotracheal suctioning *When using the ABC approach to client care, the nurse should attend to a client who requires endotracheal suctioning first. Without this intervention, mucus and secretions could accumulate and block the client's airway

A nurse manager is observing the staff working on the unit. Which of the following observations should the nurse manager recognize as an example of paternalism? A. A nurse asking to care for an older adult client every day who reminds the nurse of a favorite grandparent B. A male nurse caring for an adolescent client because the client is uncomfortable around female nurses C. A middle-aged adult assistive personnel (AP) mentoring a younger, less experienced AP on the unit D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress

A nurse practitioner withholding information from a client who is dying to avoid causing the client distress *Paternalism is a type of relationship between clients and health care providers in which the health care providers believe they know what is best for the clients. In this example, the nurse practitioner withholds information to avoid causing the client distress. This practitioner is making the decision for the client and denying the client the right to be informed

A charge nurse is conducting an in-service session on ethics for a group of newly licensed nurses. Which of the following situations should the charge nurse include as an example of the ethical principle of veracity? A. A nurse truthfully answers the client's questions about upcoming chemotherapy B. A nurse stops inserting an NG tube when the client refuses the procedure C. A nurse provides the same amount of time to all clients, regardless of illness D. A nurse reports an assistive personnel who transfers a client without using a gait belt

A nurse truthfully answers the client's questions about upcoming chemotherapy *A nurse who truthfully answers the client's questions about treatment such as chemotherapy is demonstrating the ethical principle of veracity. Veracity involves telling the truth and offering straightforward, clear information to clients about their treatments

A nurse on a pediatric unit is recommending clients for discharge following a school bus crash in the community. Which of the following clients should be recommended for discharge? A. A school-aged child admitted 1 day prior who has status asthmaticus B. A toddler admitted 1 day prior who has dehydration and is receiving IV fluids C. A preschooler who has tonsillitis and has been receiving oral antibiotics for 24 hr D. An adolescent who has acute glomerulonephritis and a urine output of 20 mL/hr

A preschooler who has tonsillitis and has been receiving oral antibiotics for 24 hr *A preschooler who has tonsillitis and is receiving oral antibiotics is stable. Therefore, this client can be discharged with antibiotics continued at home

A nurse is speaking will the family member of a client who has early Alzheimer's disease. The family member would like to keep the client living at home, but the client requires assistance while the family member is away at work. Which of the following services should the nurse include in the discussion? A. Hospice care B. Adult day care C. Assisted-living facility D. Long-term care facility

Adult day care *Adult day care personnel can provide constant assistance with ADLs while the family member is at work, allowing the client to live at home when the family member is at home

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication? A. A 3-year-old client who has a burned foot B. An 80-year-old client who has a fractured hip C. A 30-year-old client who has a cast applied for a fractured ankle D. A 42-year-old client who has an indwelling urinary catheter

An 80-year-old client who has a fractured hip *The nurse should identify that An 80-year-old client who has a fractured hip has the greatest risk for complication due to immobility and a lack of lower extremity movement, which can lead to deep-vein thrombosis (DVT). DVT is caused by venous stasis and blood clot formation in the vascular system and can create pulmonary emboli. The nurse should encourage the client to ambulate as soon as prescribed and implement range-of-motion exercises while on bedrest to prevent DVT

A nurse enters the room of an older client and finds him attempting to crawl over the side rail. Which of the following actions should the nurse take? A. Tell the client that he will be put in restraints if he attempts to get out of bed again B. Ask an assistive personnel to sit with the client C. Remind the client to stay in bed D. Restrain the client immediately to prevent self-harm

Ask an assistive personnel to sit with the client *This client is at risk of falling. Having an assistive personnel sit with the client protects him from harm. The nurse can then contact the provider to discuss care options for this client such as implementing restraints or placing an audible alarm

A nurse is caring for a client who refuses to take her prescribed oral medication. The nurse states, "If you don't take this pill, "I'm going to give you the medication by injection." A. Slander B. Battery C. Negligence D. Assault

Assault *The nurse has committed the tort of assault, which is an attempt or threat to harm another person unjustifiably. Threatening to administer an IM injection to the client if she does not take her medication orally is a form of assault

A nurse finds a client standing next to his bed with the side rails raised. The client is visibly confused and not wearing an identification bracelet, and his IV is detached. The client states, "I can't remember my name." After assisting the client back into bed, which of the following actions should the nurse perform next? A. Remind the client to use the call light B. Restart the IV C. Check the client for injury D. Put an identification bracelet on the client

Check the client for injury *Collecting additional data will provide the client to use the call light to ensure the safety of the client, but there is a different action the nurse should take first

A nurse is entering a client's room and notices the client has fallen on the bathroom floor. Which of the following actions should the nurse take first? A. Obtain support from another nurse B. Check the client for injury C. File an incident report D. Notify the client's provider

Check the client for injury *The greatest risk to this client is an injury from falling on the floor; therefore, the first action the nurse should take is to check the client for injury by looking for skin tears, cuts, or bruises and by obtaining the client's vital signs

A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first? A. Collect information related to the issue B. Consider the possible choices of action C. Make a decision regarding transplant recommendation D. Justify the recommendation for or against a transplant

Collect information related to the issue *According to evidence-based practice, the committee should take the first step in ethical decision-making, which is to identify the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation

A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which of the following actions is the charge nurse's priority? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service session about hand hygiene and infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who developed HAIs

Conduct a chart review to gather data about clients who developed HAIs *The first action the charge nurse should take using the nursing process is to collect data and gather information by conducting a chart review or audit about the clients who developed infections. This information will provide the charge nurse with potential indicators or factors that resulted in the increased incidence of HAIs

A nurse is planning to perform a negotiation to manage a conflict between herself and another staff member. Which of the following actions should the nurse plan to take? A. Continue the negotiation process until all parties agree on a settlement B. Establish equality in the concessions that each party makes C. Make as many concessions as needed to ensure everyone is happy D. Create a solution in which all parties are satisfied

Create a solution in which all parties are satisfied *The goal of negotiation is to create a win-win situation in which all parties are satisfied with the results. Both parties involved in the conflict should be willing to make concessions

A nurse is assisting with planning care for a group of clients. Which of the following actions should the nurse plan to take? A. Delegate the administration of an intermittent tube feeding to a second licensed practical nurse (LPN) B. Assign an assistive personnel (AP) to monitor a client's dressing for evidence of bleeding C. Ask an AP to explain to a client how to empty a urinary leg bag D. Delegate the administration of a unit of packed RBCs to a client to a second LPN

Delegate the administration of an intermittent tube feeding to a second licensed practical nurse (LPN) *Administering a tube feeding is within the scope of practice for an LPN

A nurse manager has established staff nurse committees to address unit issues, instituted an open-door policy for talking about concerns, and supported the professional development of all staff members. Which of the following leadership styles is this nurse manager displaying? A. Laissez-faire B. Autocratic C. Democratic D. Transformational

Democratic *The democratic manager encourages the staff to participate-making, communicates effectively, offers constructive criticism, and believes the best in people

A nurse is assisting the provider with an amniotomy for a client who is in labor. Which of the following data is the priority for the nurse to collect following the procedure? A. Color of amniotic fluid B. Fetal heart rate C. Uterine contraction pattern D. Odor of amniotic fluid

Fetal heart rate *The greatest risk to this client is an injury from umbilical cord prolapse following the artificial rupture of the membranes; therefore, the priority action the nurse should take is to monitor the fetal heart rate for bradycardia, which can indicate an increased risk of umbilical cord prolapse

A nurse is contributing to the plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. Baked pork chop B. Cheeseburger C. Ham and cheese omelet D. Grilled salmon

Grilled salmon *The nurse should recommend grilled salmon who observes Kosher dietary laws. Grilled salmon is a fish with fins and scales, which can be consumed according to Kosher practices. Seafood with shells such as lobster or crab is prohibited

A nurse manager observes a nurse entering the room of a client who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority action for the nurse manager to take? A. Speak with the nurse in a private location B. Complete an incident report C. Review competencies with the staff regarding PPE D. Have the nurse exit the room and don proper PPE

Have the nurse exit the room and don proper PPE *The nurse manager should first ensure the safety of the staff and clients by having the nurse exit the room and don proper PPE before re-entering the room

A nurse is preparing an IM injection for a client who is preoperative when another client suddenly calls for assistance. The nurse asks another nurse to give the injection because an assistive personnel is waiting to take the client to surgery. Which of the following actions should the second nurse take? A. Prepare a new syringe for the client who is preoperative B. Give the prepared medication to the client who is preoperative C. Help the other client requesting so that the first nurse can give the prepared injection D. Report this request to the charge nurse

Help the other client requesting so that the first nurse can give the prepared injection *The second nurse should help the other client so the first nurse can give the injection. The nurse who has prepared the injection is the only person who can safely identify what is in the syringe and be responsible for the correct administration of the medication

A nurse is having difficulty completing care and documentation without staying past the end of her shift. The nurse manager suggests focusing in time-management skills. Which of the following strategies should the nurse plan to incorporate? A. Practice multitasking throughout the shift B. Postpone completing documentation until the end of the shift C. Occasionally skip a break time D. Identify tasks in order of their priority

Identify tasks in order of their priority *Prioritizing is an important time-management strategy. The nurse should prioritize each client's needs and tasks and attend to the highest client first

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse when implementing the evacuation process? A. Call in the client's family members to provide additional help with moving the clients B. Ask the clients who are able to ambulate to assist with moving unstable clients C. Instruct clients who are able to ambulate to leave D. Direct staff members to close the doors and windows as each room is evacuated

Instruct clients who are able to ambulate to leave *Clients who are unable to ambulate should leave first in an evacuation process to reduce the number of clients who require evacuation assistance

A nurse is documenting data about a client at a computer terminal in the nurse's station when he has to leave the area to assist another client. Which of the following actions should the nurse take? A. Turn the computer's monitor away from the view of others B. Ask the unit clerk to make sure no one else uses that computer C. Turn off the monitor so the computer will log off automatically D. Log off the computer before leaving the nurses' station

Log off the computer before leaving the nurses' station *To ensure no one else has access to the client's protected health information, the nurse should log off the computer terminal and turn off the monitor

A charge nurse is making the daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Measuring vital signs B. Reinforcing an IV catheter's dressing C. Preoperative admission assessment D. Showing a client how to use a walker

Measuring vital signs *According to the National Council of State Board of Nursing, delegation is the transferring of authority to perform a selected nursing task in a certain situation to a competent individual. Examples of tasks a nurse can delegate to an AP are measuring and documenting vital signs, performing postmortem care, and measuring and documenting intake and output

A charge nurse overhears a unit nurse say that the charge nurse is giving preferential treatment to nurses on the night shift. Which of the following action should the charge nurse take to response to the conflict assertively? A. Understand that the unit nurse is misinformed and take no action B. Assign the unit nurse to work the night shift to allow direct experience with the night shift staff C. Meet one-on-one with the unit nurse to discuss these concerns D. Confront the unit nurse during the next unit meeting regarding the statement

Meet one-on-one with the unit nurse to discuss these concerns *The charge nurse schedules time to speak privately with the unit nurse about the situation. Assertive behavior involves discussing a situation directly with the person involved

A nurse enters a client's room and discovers a small fire in a trash can. Which of the following actions should the nurse take first? A. Place moist towels or blankets at the threshold of the door of the room with the fire B. Close fire doors and client room doors C. Pull the fire alarm and client room doors D. Move the client out of the room

Move the client out of the room *When there are several risks to client safety, the risk posing the greatest threat is the highest priority. Therefore, to ensure the safety of the client, the nurse should move the client out of the room

A nurse s assisting with the informed consent process for a client who is scheduled for a below-the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why this is happening." Which of the following actions should the nurse take? A. Complete an incident report B. Administer an antianxiety medication C. Notify the provider of the client's comments D. Answer the client's questions and verify understanding

Notify the provider of the client's comments *The nurse should notify the provider if the client has questions or appears not to understand the procedure. The provider is responsible for providing clarification. Informed consent is a legal process by which a client gives written permission for a procedure or treatment

A nurse is caring for a client who had a stroke and requires assistance performing ADLs. The nurse should collaborate with which of the following members of the interprofessional care team when caring for this client? A. Speech-language pathologist B. Occupational therapist C. Social worker D. Dietitian

Occupational therapist *An occupational therapist can help clients who have physical limitations or disabilities gain an optimal level of independence in performing ADLs such as bathing, dressing, grooming, and eating

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

Paralysis of a client's lower extremities occurred following epidural anesthesia *An incident resulting in permanent harm such as paralysis or death is a sentinel event. Sentinel events are high priority and indicate the need for immediate investigation

A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)? A. Perform a simple dressing change B. Interpret a client's blood glucose reading C. Provide advice when speaking to a client's family member on the phone D. Determine the effectiveness of a client's urinary catheter

Perform a simple dressing change is within the AP's range of function. Therefore, the charge nurse can delegate this task to an AP

A nurse is receiving report on a client who has Clostridium difficile and is being transferred from another unit. Which of the following precaution should the nurse take? A. Place the client in a negative-airflow room B. Clean the client's room with an antibacterial disinfectant C. Wear a mask when entering the client's room D. Perform hand hygiene with non-antimicrobial soap and water after performing client care

Perform hand hygiene with non-antimicrobial soap and water after performing client care *The nurse should perform hand hygiene with non-antimicrobial soap and water after providing care for a client who has C. difficile because this spore-forming organism is resistant to alcohol-based soaps and sanitizers

An RN is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to a licensed practical nurse (LPN)? A. Perform tracheostomy suctioning for a client who is stable B. Prepare an admission assessment of a client who is preoperative C. Create a plan of care for a client who has COPD D. Interpret a client's digoxin level

Perform tracheostomy suctioning for a client who is stable *An RN may delegate the task of performing tracheostomy for a client who is stable or whose tracheostomy is not new to the LPB. This task is within the LPN's scope of practice

A nurse is collecting data from a client who has recently been prescribed lithium carbonate. Which of the following findings is the nurse's priority? A. Fine hand tremors B. Weight gain of 2.7 kg (6 lb) C. Report of nausea D. Poor motor coordination

Poor motor coordination *When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is poor motor coordination, which is an advanced manifestation of lithium carbonate toxicity. The nurse should hold the client's medication and notify the provider

A nurse participating in a continuous quality-improvement program is reviewing medical records to determine the time of first postoperative ambulation of clients who had abdominal surgery. This nurse is participating in which of the following types of quality evaluation? A. Outcome B. Structure C. Strategic planning D. Process

Process *A process evaluation process measures the interventions used to facilitate expected and desired outcomes in clients. Early ambulation is essential for the prevention of postoperative complications

While orientating newly licensed nurses to a facility, a nurse manager is emphasizing the importance of practicing within standards of care. To which of the following legal concepts is the manager referring? A. Punitive damages B. Intentional tort C. Good Samaritan laws D. Professional negligence

Professional negligence *Standards of care establish safe nursing actions. Professional negligence occurs when in a nurse is acting in a manner that a reasonable and prudent nurse would not, resulting in unsafe care. Professional negligence constitutes malpractice

A nurse is assisting with the transfer of an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse plan to take? A. Discuss the client's long-term recovery goals with him B. Discuss the client's nursing care needs with his provider C. Provide a written summary of the client's nursing plan to the long-term care facility D. Review the client's nursing care plan with his family members

Provide a written summary of the client's nursing plan to the long-term care facility *A written summary of the client's nursing plan of care will convey his care needs to the nurse who will be working with him in the long-term care facility

A nurse is assisting a charge nurse with teaching a group of unit nurses about alternative restraints for clients who are confused and wandering. Which of the following pieces of information should the nurse include when reinforcing the teaching? A. Distract the client by leaving the television on B. Plan to administer a sedative to the client C. Provide the client with a rocking chair D. Place full-length side rails on the client's bed

Provide the client with a rocking chair *The nurse should recommend providing the client with a rocking chair to expend some of the client's energy through rocking rather than walking, which leads to wandering

A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following should the nurse include as the purpose of palliative care A. Curing the disease B. Producing a remission C. Hastening death D. Providing comfort measures

Providing comfort measures *Palliative care is an approach that seeks to promote comfort for a client who has a terminal diagnosis and is not receiving aggressive therapy. Palliative care focuses on managing manifestations of a disease or illness rather than on curing it

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? A. Showing the client how to use the patient-controlled analgesia B. Recording urinary output after emptying the indwelling urinary catheter C. Assisting the client out of bed into a chair for the first time after surgery D. Checking the client's abdominal wound dressing

Recording urinary output after emptying the indwelling urinary catheter *Emptying an indwelling urinary catheter and recording intake and output is within the scope of practice for an AP. This task is routine and has a predictable outcome; therefore, the nurse may delegate this task to an AP

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

Remind the client that the doctor will insert a needle to get a sample of fluid from her spine *A signed consent form implies that the provider informed the client about the procedure and that, at least at the time, the client understood what to expect. If the client states she does not remember what to expect, the nurse should clarify any information the provider previously gave the client about the details of the procedure. However, if the client expresses a further lack of understanding or states that the provider did not inform her, the nurse should either notify the charge nurse or call the provider directly

A school nurse is assisting with the care of a child who has multiple bruises to his trunk and extremities. The child reports falling out of a tree 2 days ago, but the nurse's clinical findings show patterns of bruising not typically sustained from a fall from a tree. Which of the following actions should the nurse take A. Report the findings to local police and social service agencies B. Report the findings to the school district superintendent C. Call the parents of the child and further evaluate the causative event D. Reassess the child on a weekly basis for injuries

Report the findings to local police and social service agencies *Health care providers are required to report suspected child abuse. The nurse's primary concern is for the safety of the child. Procedures for reporting will differ in various locations, but they will involve notification of police and social services personnel who can investigate the situation

A nurse suspects that a coworker might be in an impaired state when providing care to clients. Which of the following actions should the nurse take? A. Ask other coworkers if they feel the same way B. Speak directly with the impaired coworker C. Report these observations to the nurse manager D. Refuse to work with the impaired coworker

Report these observations to the nurse manager *After observing an impaired coworker's performance, the nurse should report this behavior to the nurse manager. If the coworker is found to be impaired, this action will initiate an appropriate intervention and support, and clients will be protected from the actions of an impaired coworker

A charge nurse in a long-term care facility notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the charge nurse plan to take? A. Make a general announcement at the next staff meeting asking all employees to check their adherence to the requirement B. Post a list in the employees' break room naming those who are nonadherent and the date by which they must complete the requirement C. Place a written warning in each nonadherent employee's personnel file D. Send an e-mail to each nonadherent employee with a link to upcoming educational sessions

Send an e-mail to each nonadherent employee with a link to upcoming educational sessions *E-mail provides a simple yet efficient way for the charge nurse to inform nonadherent employees about options they have for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates adherence by helping each employee identify an upcoming session that coordinates with his/her work schedule

An experienced nurse is serving as a mentor to a newly licensed nurse. Which of the following actions should the mentor perform? A. Establish a set of goals for the newly licensed nurse to achieve B. Establish a set timeframe with the newly licensed nurse for the mentorship C. Serve as a guide and teacher for the newly licensed nurse in an established relationship D. Develop a program of study for the newly licensed nurse to follow

Serve as a guide and teacher for the newly licensed nurse in an established relationship *The role of a mentor is to establish a nurturing relationship with a newly licensed nurse and be willing to invest time and resources to help the nurse develop as a professional and an individual

A charge nurse in a skilled nursing facility notes several recent conflicts among staff members on different shifts. Which of the following strategies should the nurse plan to use to resolve these conflicts? A. Ask the charge nurses for each shift to get together and discuss the issues between shifts B. Direct the staff from each shift to discuss their issues and present solutions to their charge nurse C. Set up a series of meetings for all staff members to attend to discuss issues D. Remain uninvolved and allow the staff from each shift to resolve the issues among themselves

Set up a series of meetings for all staff members to attend to discuss issues *The charge nurse is using the conflict resolution strategy of collaboration by involving the staff in order to communicate and work together to devise and implement win-win solutions

A nurse working in a mental health facility is assisting with the discharge of a client who has schizophrenia and requires housing assistance. Which of the following referrals should the nurse recommend to the provider? A. Occupation therapist B. Social worker C. Physical therapist D. Spiritual support

Social worker *The nurse should identify that a social worker assists clients with issues such as finances, day-to-day concerns, and finding suitable housing

A nurse in a provider's office observes a newly licensed nurse taking a client's health history while in the waiting area. Which of the following actions should the nurse perform? A. Continue to observe the nurse B. Speak to the nurse immediately in private C. Consider using the same practice to make efficient use of time and office space D. Report the nurse's actions to the provider

Speak to the nurse immediately in private *The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. Personal health information, which is confidential, could be overheard by others in the waiting room. The nurse must immediately stop this behavior and speak to the newly licensed nurse in private to protect the privacy and confidentiality of the client

A nurse is part of a facility committee charged with developing and implementing new documentation forms. The nurse should recognize which of the following factors as a potential restraining force for implementing this change? A. Approval of the forms by nursing administration B. Staff resistance to learning new forms of documentation C. Recognition of the facility unit that completes the implementation first D. Development of quality monitoring tools for compliance with new documentation

Staff resistance to learning new forms of documentation *Restraining forces impede change. Staff resistance to learning a new documentation system can be a restraining force. Hence, the committee must develop a plan for implementation that recognizes this threat

A nurse is walking with a client who falls after the wheel on a facility-issued walker becomes dislodged. Which of the following actions should the nurse take regarding the completed incident report? A. Document the completion of the incident report in the medical record B. Place the variance report in the client's chart C. Submit the variance to the risk manager D. Male the copy of the variance report for the provider

Submit the variance to the risk manager *Incidence reports are confidential documents used by the institution to improve client care. Filing an incident report does not replace the need for documenting the assessment of the client in the client's medical record and notifying the provider. Once completed, the variance form should be submitted to the institution's risk manager

A nurse is contributing to the plan of care for a client who has Alzheimer's disease with moderate cognitive decline. Which of the following interventions should the nurse include to orient the client to the present? A. Discourage the client from reminiscing about her past B. Overlook the client's frustration with communication C. Talk with the client about scheduled daily activities D. Present multiple options when offering the client choices

Talk with the client about scheduled daily activities *Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day

A charge nurse is planning a performance appraisal interview for a newly hired assistive personnel (AP). Which of the following factors should the charge nurse take into consideration? A. The performance appraisal interview should be friendly and informal B. Aside from the charge nurse, no one should have input regarding the AP's appraisal C. A nursing administrator who does not know the AP should conduct the interview to promote fairness D. The AP should have a copy of the performance standards before the appraisal interview

The AP should have a copy of the performance standards before the appraisal interview *The AP should have a copy of the performance standards prior to the interview in order to understand the standards that his/her performance is being measured against

A nurse is assisting with teaching a group of unit nurses about the Health Insurance Portability and Accountability Act (HIPAA).Which of the following pieces should the nurse include in the teaching? A. The Privacy Rule limits the client's rights to personal health information B. The electronic transfer of information allows each provider to use/her own electronic format for claim transactions C. Standardized numbers can have a varied format for identifying health plans D. The Security Rule provides a uniform level of security to protect client records

The Security Rule provides a uniform level of security to protect client records *The security rule provides a uniform level of protection of client's records, which includes maintaining the confidentiality, integrity, and availability of the client's records

A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates an understanding of the teaching? A. The client nods and smiles in response to what is being said B. The client does not ask questions when given the opportunity C. The client does not ask questions when given the opportunity D. The client's body language shows that she is listening to the nurse

The client does not ask questions when given the opportunity *The client restating the information in her own words is the best way for the nurse to assess the client's understanding of the teaching. The nurse can observe and listen for gaps in understanding and then correct them as necessary

A nurse is assisting with making assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Instructing a client how to use a glucometer B. Instilling lubricating eye drops for a client C. Evaluating the effectiveness of a client's pain medication D. Transferring a client who is postoperative from a bed to a chair

Transferring a client who is postoperative from a bed to a chair *Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, and other simple procedures that do not involve assessment or teaching

A nurse is walking down the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take? A. Place unused equipment between the fire doors B. Turn off sources of oxygen near the fire C. Place rolled blankets at the base of the fire D. Keep doors to the unit and client rooms open

Turn off sources of oxygen near the fire *Oxygen fuels fire, so the nurse should turn off all sources of oxygen near the fire

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

The person who will perform the procedure is responsible for obtaining informed consent *The person performing the procedure is legally responsible for obtaining informed consent. Informed consent includes telling the client about the risks and benefits of the procedure, alternative treatments available, and possible outcomes if the procedure is not performed

A nurse is following policy and procedure for reporting a client who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC? A. Clostridioides difficule B. Candidiasis C. Vancomycin-resistant Staphylococcus aureus D. Trichomoniasis

Vancomycin-resistant Staphylococcus aureus *The nurse should follow policy and procedure for reporting a client who has Vancomycin-resistant Staphylococcus aureus, a communicable disease, to the CDC

A nurse in a community health clinic is planning an in-service session on nationally notifiable infectious conditions. Which of the following conditions should the nurse include? A. Clostridioides difficle B. Varicella C. HIV exposure D. Influenza

Varicella *The nurse should identify that varicella is a nationally notifiable infectious condition

A nurse manager is planning to discipline a nurse who has been absent from work 6 times in the past 6 weeks for various reasons. Because this is the first instance of a potential problem with the employee, the nurse manager decides to utilize a nonpunitive approach to the absenteeism. Which of the following actions should the nurse manager plan to take? A. Terminate the employee for repeated absenteeism infractions B. Place the nurse on disciplinary leave for 1 week C. Inform the employee in writing about the facility's employment policy D. Verbally remind the employee about the facility's employment standards

Verbally remind the employee about the facility's employment standards *Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder might be all that the employee needs to change the behavior

A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following tasks is the responsibility of the nurse? A. Explain the procedure to the client B. Offer alternative treatments C. Inform the client of the consequences of refusing the procedure D. Verify the client understands the procedure being performed

Verify the client understands the procedure being performed *The nurse must verify that the client understands and can describe the procedure being performed