communitty assessment

A nurse in an acute care facility is caring for a client who is leaving against medical advice (AMA). Which of the following actions should the nurse take? (Select all that apply.)

-Request the client sign an AMA form. -Notify the provider of client's intent. -Advise the client about the dangers of leaving.

* Initiate IV sire, Infuse o.9, RBC, Verfy , Spike *Federal Legislation *National Guildness clearing house *PSDA *Critical Pathway *Shiggles-glove-gown *Chest Tube & Tracheal deviation *Funtional Nursing *Report Pus-likedrainage *Outcome *9ml

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A nurse manager on a maternal newborn unit is completing a chart audit to determine the percentage of clients over the past 3 months who breastfed their newborns successfully prior to discharge. Which of the following standards is the nurse using to complete this audit?

Outcome

A charge nurse is planning an in-service for a group of nurses about caring for clients who have active tuberculosis. Which of the following information should the charge nurse include in the in-service?

Place clients in a negative pressure room.

A nurse is providing care to a group of clients. Which of the following steps should the nurse plan to take to manage time effectively? (Select all that apply.)

-Organize tasks around the priority needs of the clients. -Create a list of all planned activities. -Delegate tasks to assistive personnel.

A charge nurse in an acute care facility is teaching a newly licensed nurse about caring for an adult client who is cognitively impaired. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will assign the client to a room close to the nurses' station."

A nurse is preparing a client for a surgical procedure to continue the revision of a large burn scar on the left arm. The client tells the nurse that they want to cancel the procedure. Which of the following responses should the nurse make?

"I will inform the provider of your decision."

. A nurse is providing teaching for a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

"My health care proxy will make my health care decisions when I am no longer able."

A nurse is providing discharge teaching to a client's adult child regarding the client's discharge to home with hospice care. Which of the following statements by the client's adult child indicates an understanding of the teaching?

"The hospice team will provide services for the entire family, not just my father."

A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses discussing the biopsy results of a client who is on the unit. Which of the following actions should the nurse take? (Select all that apply.)

-Plan an in-service program for the nurses about HIPAA privacy rules. -Ask the nurses to stop discussing the client's protected health information. -Inform the nurse manager about the confidentiality breach.

A nurse manager is meeting with a staff nurse who is consistently late for work. Which of the following statements by the nurse manager demonstrates an assertive communication style?

"When you come to work late, I am concerned that client care will be jeopardized."

A nurse is assisting a client who is scheduled to undergo a hysterectomy after signing an informed consent form. The client states, "Signing this form makes me nervous." Which of the following responses should the nurse make?

"Would you like to speak with the provider again?"

A charge nurse is conducting an in-service on advocacy for a group of newly licensed nurses. Which of the following examples should the charge nurse include in the teaching as a demonstration of client advocacy? (Select all that apply.)

-A nurse reports a procedure was completed incorrectly by another nurse to the charge nurse. -A nurse arranges for an interpreter for a client who speaks a different language.

A charge nurse is observing a newly licensed nurse administer a unit of packed RBCs to a client. The charge nurse should identify the nurse has completed the procedure correctly when he completes the steps in which order? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

3. Obtains the unit of packed RBCs for transfusion from the blood bank 4. Verifies the information on the blood bag with client's medical record and arm bracelet 1. Initiates an IV site with an 18-gauge IV catheter 5. Inserts the Y spike from the tubing into the blood bag Infuses 0.9% sodium chloride solution

A nurse in a long-term care facility is caring for a group of clients. The nurse should prioritize which of the following clients for an interdisciplinary care conference?

A client who is 1 week postoperative following a hip fracture

A nurse is planning care after receiving report for four clients. Which of the following clients should the nurse plan to assess first?

A client who is 2 days postoperative and has a urinary output of 500 mL/24 hr

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?

A client who is postoperative and has respiratory rate of 10/min

A nurse is prioritizing care for four clients. Which of the following clients is the nurse's priority?

A client who is postoperative following a thyroidectomy and reports tingling around their mouth.

A nurse is performing mass casualty triage of clients following a tornado. Which of the following clients should the nurse identify as a priority for transportation to the acute care facility?

A middle-adult client who has a severed lower extremity

A nurse manager is planning the staff's annual performance appraisals. Which of the following locations should the nurse manager choose to conduct the appraisals?

A private office with the door closed

A nurse is assessing a client who is 4 hr postoperative following an open appendectomy. Which of the following manifestations should indicate to the nurse that the client requires a nasogastric tube with low intermittent suction?

Abdominal distention

A nurse manager is evaluating staffing needs for a unit, including the need for overtime hours. Which of the following actions should the nurse manager implement first?

Access computerized data correlating client acuity, staffing, and scheduling

A nursing supervisor in an acute care facility has to recommend a client for discharge to make room for a client who was injured during an explosion. Which of the following clients should the nurse recommend for discharge?

An older adult client who had a total knee arthroplasty 1 week ago

A nurse is developing a plan of care for a client who is immobile and at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan?

Apply moisturizing lotion to the client's skin after bathing.

A charge nurse is assigning tasks for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Collect a urine sample for urinalysis.

A nurse is using the situation, background, assessment, recommendation (SBAR) format to provide hand-off report for a client. In which of the following components of the SBAR report should the nurse include information about the client's current vital signs?

Assessment

A nurse is caring for a client who received pain medication 1 hr ago. The client tells the nurse the medication is not working because they are still experiencing pain. Which of the following actions by the nurse demonstrates client advocacy?

Attempt to obtain a prescription for a different analgesic medication.

A nurse is delegating client care on a labor and delivery unit. Which of the following tasks should the nurse delegate to assistive personnel (AP)?

Complete I&O on clients who are in active labor.

A nurse encounters a client sitting on the floor in the hallway. The client says they slipped on some water on the floor and now their arm hurts. Which of the following actions should the nurse take first?

Check the client for injuries.

A nurse manager is scheduling a meeting to address a conflict between staff members and a client's family. In the meeting, staff and family members will identify common goals and express their concerns. Which of the following conflict resolution strategies is the nurse manager implementing?

Collaboration

A nurse is performing morning rounds for a client and finds the client's bedtime medications sitting at the bedside in a medication cup. Which of the following actions should the nurse take?

Contact the charge nurse to complete an incident report.

A nurse in an acute care facility is preparing to discharge an older adult client to home. Which of the following actions by the nurse demonstrates client advocacy?

Contacting a social worker to assist the client with daily meal delivery services

A nurse manager calls a staff nurse to come in and work due to staffing shortages on several units. The staff nurse is at home and has influenza. Which of the following actions by the staff nurse demonstrates the ethical principle of fidelity?

Decline because nurses should not work when ill.

A nurse manager is implementing a plan to motivate unit personnel to provide quality care to clients on the unit. Which of the following leadership strategies should the nurse manager implement to improve client care

Democratic leadership

A nurse is developing a plan of care for a client who has chronic kidney disease. The client gives the nurse copies of his advance directives which state that he does not want to begin dialysis. Which of the following actions should the nurse include in the plan?

Document within the medical record that the client has advance directives in place.

A nurse manager is considering changing the policy for administering medications to clients on a unit. Which of the following actions should the nurse manager take first?

Determine the unit staff's perception of the need for change.

A nurse in an emergency department is assessing an adult client from a long-term care facility who has a developmental disability. The nurse observes bruises in various stages of healing. The client denies any abuse and tells the nurse not to report the findings. Which of the following actions should the nurse take?

Document the findings for the provider.

A nurse manager suspects that a staff nurse on the night shift has a substance use disorder. Which of the following actions should the nurse manager take?

Document thoroughly any unusual behavior by the nurse.

A nurse manager is changing the ratio of registered nurses (RNs) to licensed practical nurses (LPNs) on a unit to decrease costs. Which of the following strategies should the nurse manager implement to reduce resistance from the staff?

Formulate a sample staffing schedule covering 1 month.

A nurse manager is anticipating a period when staffing will be especially short. The nurse manager decides to reorganize the delivery of care on the unit until staffing improves by appointing a charge nurse, a medication nurse, and a treatment nurse. Which of the following delivery systems is the nurse manager using?

Functional nursing

A nurse manager is conducting a disaster-preparedness drill and observes nurses applying triage tags to clerical staff who are posing as injured clients. The manager should expect the nurses to apply which of the following tags to a client who has an ankle sprain?

Green

A nurse suspects a client is developing opioid use disorder and reduces the client's dosage of pain medication by 50% without a prescription from the provider. The nurse checks on the client 1 hr later and sees the client sitting up in a chair. The client tells the nurse, "I am in too much pain to reach the nurse call button." The nurse is liable for which of the following legal violations?

Gross negligence

A charge nurse is following up on a task delegated to another nurse and discovers an error that could harm the client. Which of the following actions should the charge nurse take?

Implement interventions to ensure the client's safety.

A nurse in an emergency department is admitting a 15-year-old client who is accompanied by her grandparent. The client requires an open reduction and internal fixation of several fractures. The nurse confirms that the client's parents are out of the country. Which of the following actions should the nurse take?

Inform the provider to ask the grandparent to provide consent.

A nurse is caring for a client who was involved in a motor vehicle crash with his partner. The client asks the nurse about his partner's condition. Which of the following actions should the nurse take?

Let the client know that he will be updated as soon as possible

A nurse at a long-term care facility discovers flames coming from a trash can in the day room. Which of the following actions should the nurse take first?

Move the clients to an area of safety.

A nurse from an acute pediatric unit who has not cared for adult clients in more than 5 years is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take?

Negotiate specific tasks to perform with the nursing supervisor.

A nurse is caring for a client who is 4 hr postoperative following an appendectomy. While reviewing the client's postoperative prescriptions, the nurse notes a medication dosage greater than twice the expected amount and notifies the provider for clarification. Which of the following ethical principles is the nurse demonstrating?

Nonmaleficence

A nurse manager witnesses an assistive personnel (AP) using incorrect procedure when transferring a client using a mechanical lift. After reinforcing proper procedure, which of the following methods should the nurse manager use to evaluate the AP's understanding of the teaching?

Observe the AP's technique with the lift at random times throughout the day.

A nurse is admitting a client who has heart failure and speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client using an interpreter?

Observe the client's nonverbal expressions.

A nurse is planning care for a client who has hemiparesis and dysphagia following a stroke. The nurse should collaborate with which of the following members of the interprofessional team to assist the client with managing ADLs? (Select all that apply.)

Occupational therapist Physical therapist Speech-language pathologist

A nurse is teaching a group of newly licensed nurses about caring for a client who has Clostridium difficile. Which of the following instructions should the nurse include in the teaching?

Put on a gown when caring for the client.

A charge nurse is teaching a newly licensed nurse about providing written discharge instructions for a client who is postoperative following an arthroplasty. The charge nurse should identify that which of the following discharge instructions written by the newly licensed nurse indicates understanding of the teaching?

Report pus-like drainage from the wound.

A nurse is planning for the discharge of a client who has advanced lung cancer. The client's partner tells the nurse that she plans to manage the client's care at home but she is concerned about leaving the client alone to attend to personal errands. Which of the following services should the nurse suggest?

Respite care

A nurse manager is providing disciplinary action for a staff nurse who is claiming 1 hr of overtime every day for the past month to complete computer documentation. Which of the following actions should the nurse manager take first?

Speak with the nurse regarding the incident.

A nurse is planning interdisciplinary care for a client experiencing an exacerbation of myasthenia gravis. Which of the following information should the nurse plan to communicate to an occupational therapist?

The client has difficulty grasping eating utensils.

A nurse is using the SBAR communication tool for reporting a client's condition to the provider. Which of the following information should the nurse include in the "S" portion of the tool?

The client is reporting a pain level of 8 on a scale from 0 to 10.

A nurse is teaching a newly licensed nurse about do-not-resuscitate (DNR) orders. Which of the following information should the nurse include in the teaching?

The provider should periodically evaluate the DNR order.

A nurse manager is preparing a nurse's performance appraisal. Which of the following actions should the nurse manager take?

Use a formalized system to discuss important issues.

A nurse manager is performing a record audit as part of the unit's quality improvement program. The nurse should identify that which of the following examples demonstrates the correct use of approved abbreviations in a medical record?

Zolpidem 5 mg PO at bedtime

A nurse manager is working with a team to resolve an ethical dilemma. Which of the following steps should the team take to make an informed decision? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

· Identify and state the nature of the ethical dilemma. · List actions to take based on a list of alternatives. · Decide to select one alternative. · Communicate the justification for the decision.