Leadership Exam #1
a nurse is caring for a client who has recently been prescribed lithium carbonate. Which of the following assessment findings is the priority for this client? a. fine hand tremors b. weight gain of 2.7 kg c. Report of nausea d. Poor motor coordination
Answer: D lithium toxicity
A nurse manager is implementing a team nursing approach on his unit, hiring LPNs and AP as additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change? a. Develop a plan for the change and present it during a staff meeting b. Explain that this change is a request from the administration and will be carried out c. Hire new LPNs and APs and gradually integrate them into the staff d. Introduce the new approach and facilitate the development of a task force to plan implementation
Answer: D
A nurse manager notes that several staff members are late in completing an annual mandatory educational session about extremity restrain safety. Which of the following actions should the nurse manager 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 non adherent and the date by which they must complete the requirement c. Schedule a disciplinary conference with each of the non-adherent employees d. Send an email to each non-adherent employee that includes a link to upcoming educational sessions
Answer: D
A nurse on a medical-surgical unit is delegating tasks to nursing team members. Which of the following tasks should the nurse delegate 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
Answer: D
A nurse is selecting clients for discharge following an environmental disaster. Which of the following clients should the nurse select? a. A client who has a cast removal due to compartment syndrome b. A client who is scheduled for dialysis and has a potassium level of 6.2 c. A client who has type 1 diabetes mellitus and a blood glucose of 320 d. A client who is 1 day postoperative following an inguinal hernia repair
Answer: D
A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular ancient (CVA). Which of the following should be the priority of the nurse? a. Administer medications with meals when possible b. Ensure client understanding of medication's effects c. Determine the client's ability to self-administer medications d. Have the client position the head with the shin down while swallowing
Answer: D -ABC approach
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
Answer: D -ABC approach -mucus and secretions could accumulate and block the client's airway
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? a. Place O2 at @L per nasal canal on the client b. Place the client in the orthopedic position c. Perform chest percussion d. Perform nasotracheal suctioning
Answer: B -allows for maximum chest expansion
A charge nurse is making daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel? a. Measuring vital signs b. Reinforcing an IV catheter dressing c. Conducting a preoperative admission assessment d. Showing a client how to use a walker
Answer: A
A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an AP a. Perform a simple dressing change b. Interpreting a client's blood glucose reading c. Providing advice when speaking to a client's family member on the phone d. Determining the effectiveness of a client's urinary catheter
Answer: A
A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first? a. Hemothorax b. Open humeral fracture c. Multiple deep abrasions on the arms and face d. Superficial partial-thickness burns on both legs
Answer: A
A nurse is admitting a client who has measles. This client should be placed in which of the following types of isolation? a. Airborne b. Contact c. Droplet d. Protective environment
Answer: A
A nurse is caring for a client who has a serum potassium level of 3.1. Which of the following actions should the nurse take first? a. Obtain an ECG b. Administer oral potassium c. Encourage potassium-rich foods d. Monitor I & O
Answer: A
A nurse is 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 licensed practical nurse (LPN) b. Assign an assertive 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 an LPN
Answer: A
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome. Which of the following is the highest priority to include in the instructions? A. Place the infant in a supine position when sleeping b. Place the infant on a firm mattress when sleeping c. Avoid covering the infant with loose bedding while sleeping d. Avoid leaving stuffed animals in the crib with the sleeping infant
Answer: A
A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel (UAP). Which of the following activities should the nurse manager perform first? a. Determine the learning needs of the UAPs b. Administer a skills pretest to the new UAPs c. Provide the new UAPS with the performance checklist d. Ask the UAPs about any weaknesses they may have
Answer: A
A nurse receives the morning change-of-shift report and delegates several tasks to an aP on the team. Which of the following tasks should the nurse instruct the AP to perform first? a. Obtain the morning capillary blood glucose tests b. Bathe a client scheduled for physical therapy at 0900 c. Distribute the breakfast trays d. Fill pitchers with fresh water and ice
Answer: A
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiacs arrest. Which of the following actions should the nurse take first? a. Check on the client b. Unlock the crash cart c. Begin cardiopulmonary resuscitation d. Announce a code
Answer: A
A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies to help reduce costs. Which of the following types of leadership is the nurse manager using? a. Autocratic b. Democratic c. Laissez-faire d. Moral
Answer: B -asking for staff input
A nurse manager believes that a nurse is taking breaks that are too frequent and lengthy. Which assertive statements should the charge nurse use to initiate a discussion of the issue? a. I understand you are allowed to take scheduled breaks during each shift but you are taking more than the number allocated. Let's set a time when we can discuss this behavior b. you are taking more breaks during each shift than hospital policy allows. you will need to take only the number of breaks specified and ensure you are back on time c. You have been taking too many breaks during each shift and do not return on time after your break. I will have to make a formal note about this issue that will be reflected on your next performance appraisal d. Why do you take so many breaks? Are you aware there is a policy that designates how many breaks you can take?
Answer: A -assertive communication uses "I" statements that describe observation/feelings -a verbal discourse can follow that allows an open discussion of the issue
A nurse is delegating a client care task to an AP. Which of the following directions should the nurse give the AP? a. This client needs to ambulate using a walker three times today b. Please record strict intake and output for this client c. This client needs to have blood glucose monitoring before each meal d. Please obtain vital signs from all the clients to whom you are assigned today
Answer: A -provides specific detail
A charge nurse in an emergency department is making assignments for an AP during a shift with unexpected staff absences. Which of the following assignments should the charge give to a float AP from the medical-surgical unit? a. Escorting clients from the emergency department to other areas of the facility for tests b. Sitting at the reception desk answering telephones and directing clients c. Restocking the examination rooms after each client is discharged d. Shadowing an AP who is regularly assigned to the emergency department
Answer: A -restocking is not an appropriate task because the equipment in the treatment and exam rooms of the ED must be readily available in the event of an emergency
A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a non punitive approach, which of the following activities should the nurse manager take? a. Verbally remind the employee about the facilities employment standards b. Recommend that the employee review the facilities policy regarding absences c. Inform the employee in writing about the facility's employment policy d. ask the employee for a written action plan discussing the reason for these absences
Answer: A -verbal admonishment is the first step in the disciplinary process for this type of infraction
A nurse is planning care for several clients. Which of the following clients should the nurse refer to case manager? a. A client who has a neurological deficits following a stroke b. A married female client who has delivered a full-term newborn c. A client who us postoperative following a cholecystectomy d. A child who has a fracture of the dominant arm
Answer: A A married female client who has delivered a full-term newborn -a client who has ongoing needs for care/rehab should receive care that is directed by a case manager due to the complexity and cost of the client's needs
A nurse is caring for 4 clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client? a. Cerebral arteriogram b. Magnetic resonance imaging (MRI) c. Computed tomography (CT) scan d. Carotid ultrasound
Answer: A Cerebral arteriogram -because it is considered invasive because it involves injecting contrast material into an artery to study the cerebral circulation
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. Performing tracheostomy suctioning for a client who is stable b. Preparing an admission assessment for a client who is preoperative c. Creating a plan of care for a client who has COPD d. Interpreting a client's digoxin level
Answer: A Performing tracheostomy suctioning for a client who is stable -an LPN may provide tracheostomy suctioning for a client who is stable or whose tracheostomy is not new -B: is not correct because an admission involves assessment, which is the RNs responsibility
A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict-resolution styles is an example of one nurse putting aside personal goals to satisfy the other nurse? a. Avoidance b. Accommodation c. Compromise d. Collaboration
Answer: B
A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge assign to a licensed practical nurse? a. A client who is to be discharged with a peripherally inserted central catheter line b. A client who is disoriented and awaiting a transfer to a long-term care facility c. A client who is 16 hours postoperative following a total laryngectomy d. A client who is newly admitted for abdominal pain of unknown origin
Answer: B
A charge nurse is making shift assignments for a team that includes RNs, LPNs, and assistive personnel. Which of the following clients should the nurse assign to an LPN? a. A client who was just admitted by the unit staff for recurring angina b. A client who has emphysema and pneumonia and is receiving oxygen c. A client who has breast cancer and is receiving chemotherapy d. A client who was just admitted by the unit staff for a cerebrovascular accident
Answer: B
A charge nurse is providing teaching to a new staff nurse about the management of a team consisting of a LPN and an AP. Which of the following pieces of information should the charge nurse include in the teaching? a. The LPN can delegate the task of teaching a client about foot care to the AP b. The LPN should be familiar with the task she plans to delegate c. The person who accepts the delegated task also assumes accountability for the task d. The LPN can delegate an initial assessment of a client to the LPN
Answer: B
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? a. Administer an anticoagulant b. Check the leg for warmth and edema c. Apply elastic stockings d. Promote bed rest and extremity elevation
Answer: B
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 assertive personnel (AP)? a. Showing the client how to use the patient-controlled analgesia pump b. Recording urinary output after emptying the indwelling urinary catheter c. Assisting the client out of bed and into a chair for the first time after surgery d. Checking the client's abdominal dressing
Answer: B
A nurse is delegating a task to an AP. The AP is to transfer a client who has a below-the-knee amputation from a bed to a wheelchair. The AP has never transferred a client with an amputation before. Which of the following actions should the nurse take? a. Provide the AP with a manual on how the transfer should be done b. Assist the AP after he has practiced the transfer c. Transfer the client while the AP observes d. Ask another AP to transfer the client
Answer: B -by assisting the AP with the first transfer, the nurse helps ensure that delegated care is safely provided -C is another possible strategy but it does not allow hands on practice for the AP
A nurse manager established staff nurse committees to address unit issues, institutes an open-door policy for speaking about concerns, and supports professional staff development. Which of the following leadership styles is this nurse manager displaying? a. Laissez-faire b. Democratic c. Autocratic d. Transactional
Answer: B -encourages staff to participate in decision-making, communicates effectively, offers constructive criticism, and believes the best in people -A: provides little structure or direction for a group -C: making decisions without staff input, focusing on task completion, and limiting access to communication with the manager -D: focuses on getting work done and the tasks to be completed
A nurse from a facility's float pool received an assignment to float on a nursing unit. The float nurse tells the charge nurse that she has never worked on this unit before. How should the charge nurse respond? a. I'll be sure to give you an easy assignment so you won't have any difficulty adjusting to our unit b. I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you c. Don't worry about that. Come find me if you have any questions, and I will try to help d. I'll call the supervisor and ask if another float nurse is working who has experience with out unit
Answer: B -not A: providing the float nurse with an easy assignment will not address the need to be properly oriented to the unit
A nurse is delegating tasks to an AP for the care of a group of clients. Which of the following directions should the nurse provide? a. Take the temperature of the client in room 200 b. Transport the client in room 203 to the radiology department at 1000 c. Obtain the vital signs of the client in room 205 when he returns from surgery d. Contact the provider of the client in room 208 regarding her decreased hemoglobin level
Answer: B -rights of delegation -right communication
A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to an assistive personnel (AP)? a. Verify the client's list of allergies in the medical record b. Assist with placing the client onto the stretcher for transport to the surgical suite c. Complete the preoperative checklist for the client d. Call to inform the provider about the client's preoperative elevated blood glucose level
Answer: B . Assist with placing the client onto the stretcher for transport to the surgical suite
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 into bed d. Complete an incident report
Answer: B Check the client for injuries -first step in the nursing process is to assess
A group of providers is participating in a cardiopulmonary resuscitation effort for a client who is in cardiac arrest. Which of the following types of leadership is required for this group to function efficiently? a. Transformational b. Participative c. Autocratic d. Laissez-faire
Answer: C
A nurse finds a client standing next to his bed with the side rails raised. The client 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 take next? a. Remind the client to use the call light b. Restart the IV c. Assess the client for injury d. Put an identification bracelet on the client
Answer: C
A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? a. Providing pain control b. Preventing hemorrhage c. Maintaining a patent airway d. Ensuring adequate fluid intake
Answer: C
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
Answer: C
A nurse is collecting data on four clients. Which of the following findings is the most urgent? a. Bladder distention and urgency b. Pedal edema c. Warmth and pain in the calf d. Hypoactive bowel sounds
Answer: C
A nurse is preparing to care for a group of clients after receiving change-of-shift reports. Which of the following clients should the nurse assess first? a. A client who has benign prostatic 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
Answer: C
Due to staffing shortages a nurse manager floats a medical-surgical nurse to the pediatric unit. This nurse has limited experience with children. Which of the following actions should the nurse manager take? a. Provide constant supervision for the medical-surgical nurse b. Have the medical-surgical nurse provide relief for unit nurses during break and lunch times c. Assign a unit nurse to act as a resource for the medical-surgical nurse d. Delegate assistive personnel tasks to the medical-surgical nurse
Answer: C
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 updated 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 has just arrived from PACU and requires a head-to-toe assessment
Answer: C -LPNs cannot assess, perform teaching to patients, and cannot partake in plan of care for a patient
A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict? a. Understanding that the unit nurse is misinformed and taking no action Assigning the unit nurse to work the night shift to facilitate direct experience with the night shift c. Meeting one-on-one with the unit nurse to discuss these concerns d. Confronting the unit nurse during the next unit meeting regarding this statement
Answer: C -assertive behavior involves discussing a situation directly with the person involved
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 since 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 client requesting assistance so the first nurse can give the prepared injection d. Report this request to the charge nurse
Answer: C -never give medication that you have not witnessed another nurse prepare
A nurse is admitting a client who has active gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)? a. Obtain the initial set of vital signs b. Listen for bowel sounds c. Show the client how to use the nurse call light d. Ask the client if he has any allergies
Answer: C -the nurse cannot delegate the AP to obtain the initial set of vital signs because she must assess the client prior to delegating tasks to determine if the client is medically stable
A nurse is caring for a client who asks if the client in the next room is in pain because she cries out frequently. Which of the following statements should the nurse make? a. That client has cancer and is quite uncomfortable 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 the client's family when they visit?
Answer: C -therapeutic response that focuses on the client's feelings rather than on confidential information
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? a. Establishing a sense of achievement b. Contributing to society c. Creating meaningful social relationships d. Enhancing self-confidence
Answer: C -third level of Maslow -first level is physiological needs -second is safety and security -this is love and belonging -confidence is the fourth level
A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the client on the floor. What is the priority nursing action? a. Notify the provider of the fall b. Call for help c. Determine the client's level of consciousness d. Complete an incident report
Answer: C Determine the client's level of consciousness -this client might have had a vasovagal response while defecating resulting in a temporary loss of consciousness that does not require CPR
A new nurse manager on a busy oncology unit keeps her door closed when she is in the office and does not offer to help resolve daily staffing issues. Which of the following types of leadership behavior is this nurse manager displaying? a. Transformational b. Democratic c. Autocratic d. Laissez-faire
Answer: D
A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? a. A client who has history of heart failure b. A client who has type 1 diabetes mellitus c. A client who is reporting pain associated with osteoarthritis of the knee d. A client who s having a nosebleed associated with hypertension
Answer: D
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? a. A client who has peripheral vascular disease and reports numbness in the toes b. A client who has depression and is easily distracted c. A client who has Alzheimer's disease and is unable to complete activities of daily living d. A client who had abdominal surgery 10 days ago and reports feeling his incision pop
Answer: D
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? a. Initiate oxygen therapy b. Encourage an increase in oral fluids c. Provide room humidification d. Assist client to cough effectively
Answer: D
A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should nurse take first? a. Ensure all four side rails are up b. Administer a prescribed sedative c. Place the client in soft wrist restraints d. Move the client to a room near the nurses' station
Answer: D
A nurse is caring for a postoperative client who has an Hgb of 8.0 g/dL. The nurse delegates the administration of a unit of packed RBCs to a nurse floating from psychiatric unit who is unfamiliar with blood administration. Which of the following actions should the float nurse take? a. Call the provider to clarify the prescription for administering the unit of packed RBCs b. Hang the unit of blood if the charge nurse agrees to be a resource c. Question the nurse regarding this prescription due to the client's reported Hgb level d. Decline to hang the blood
Answer: D
A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel. Which of the following tasks should the nurse direct the AP to perform first? a. Change the transparent dressing on a client who has a stage 2 pressure ulcer b. Bring a pitcher of fresh water to client who has just had a lumbar puncture c. Transport a client to the radiology department for a routine chest X-ray d. Take an arterial blood gas specimen to the laboratory
Answer: D
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? a. Malaise b. Headache c. Anorexia d. Diarrhea
Answer: D
A nurse on a medical-surgical unit is planning the care of assigned clients. Which of the following clients should the nurse attend to first? a. A client who is newly admitted and is scheduled for indwelling urinary catheter insertion b. A client who has kidney stones and reports flank pain of 6 on a pain scale of 0-10 c. A client diagnosed with early stage chronic kidney disease with 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
Answer: D -circulation -tingling, numbness, pallor, paresthesia, and pain are clinical manifestations associated with compartment syndrome
A charge nurse finds an increased incidence of health-care-associated infections on a long-term care unit. Which priority should the charge nurse take to address the problem? a. Monitor the staff's hand hygiene techniques b. Hold a mandatory in-service training session about hand hygiene 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
Answer: D -first conduct a chart review or audit in order to gather data
A nurse is having difficulty completing care and documentation without staying past the end of the shft. The nurse manager suggests focusing on time-management skills. Which of the following strategies should the nurse plan to use? 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
Answer: D -prioritizing is an important time-management strategy -the nurse should prioritize each client's needs and attend to the highest priority client first
A charge nurse receives a call from the nursing supervisor about an explosion at a local factory and an urgent need for facility beds for newly admitted clients. Which of the following clients should the nurse recommend for discharge? a. A 60-year-old client with type 2 diabetes mellitus who was admitted 48 hours ago with uncontrollable glucose levels b. A 58 year-old client who is 12 hours postoperative following a total knee arthroplasty c. An 80-year-old client admitted 24 hours ago for vomiting and dehydration d. A 44-year-old client with asthma who was admitted for carpal tunnel surgery
Answer: D -the client is having an elective surgery
A nurse is working with an AP in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? a. Whether the AP has consented to the performance of delegated tasks b. The client's willingness to consent to care from the AP c. Whether the task can be more efficiently completed by the nurse d. The degree of supervision that the AP will require to complete the task
Answer: D -the person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided -the right communication of expectations and the right feedback about performance must be supplied
An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel obstruction and is NPO with nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform? a. Obtain daily weight b. Inspect the client's oral cavity for dryness hourly c. Measure and record the NG tube output every 4 hours d. Assess for bowel sounds every 2 hours
Answer: D -while assessing is only within the scope of practice for the RN only, LPN can auscultate the client's abdomen for presence of sounds. -Only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive
A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse? a. Explaining the procedure to the client b. Offering alternative treatments c. Informing the client of the consequences of refusing procedure d. Verifying the client's understanding of the procedure being performed
Answer: D Verifying the client's understanding of the procedure being performed
A charge nurse is planning a department in-service training session about radioactive implants for a group of staff nurses. Which of the following points should the charge nurse include in the presentation? 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 members 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 if they are accompanied by an adult
Answers: A,C,D
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? 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
Answers: A,C,D
A nurse manager is evaluating the time-management strategies of a newly licensed nurse on the pediatric unit. Which of the following actions taken by the nurse are effective time-management strategies? Select all that apply a. Completing one 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 more time-consuming tasks at the end of the shift e. Mentally visualizing a procedure prior to gathering equipment
Answers: A. Completing one task before beginning another task, C. Taking time to plan care at the beginning of the shift , E. Mentally visualizing a procedure prior to gathering equipment -B is not correct because the nurse should complete more difficult or strenuous tasks earlier in the day when energy levels are higher. This strategy also helps avoid procrastination
A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? Select all that apply a. Administer the medication to the client b. Notify the provider c. Complete a variance report d. Document the finding in the client's electronic medical record e. Place the medication back in the medication drawer
Answers: B, C
A charge nurse is planning an in-service training session about client advocacy with 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 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 outlines in the living will of an older adult client who has end-stage renal disease
Answers: B,C,D,E
A charge nurse on a medical-surgical unit is assigning client care to the upcoming shift. Which of the following tasks should the nurse delegate to an AP? a. Performing colostomy care b. Measuring a client's intake and output c. Interpreting a client's laboratory values following surgery d. Providing postmortem care to a client e. Checking nasogastric tube patency
Answers: B,D