Management Concepts

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gesture 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

1. Ask the interpreter to explain the discussion An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The role does not include personally editorializing or embellishing with advice beyond what the health care provider (HCP) said. It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about other topics (eg, social). The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no additional questions that the interpreter personally answered. The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line. After the nurse is satisfied that no additional information was provided and the client understands what the client is signing, the nurse (as the hospital employee) should then witness the signature. The nurse should indicate that an interpreter was used in the process. Educational objective:An interpreter should only provide literal translation of the words spoken by the HCP, not adding any personal advice/information. The nurse should clarify if there is any question about the accuracy or content of the translation and ensure the client's concerns have been addressed prior to obtaining the signature on the consent.

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply. 1. Facilitating communication between health care providers (HCPs) 2. Obtaining health information from the client's nursing home 3. Reconciliation of home medications 4. Referral for home health after discharge 5. Visiting the client daily while hospitalized

1. Facilitating communication between health care providers (HCPs) 2. Obtaining health information from the client's nursing home 4. Referral for home health after discharge Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases fragmentation of care (Option 2), helps to coordinate care and communication between HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge (Option 4). Educational objective:The nurse providing direct client care should be familiar with the nurse case manager role as part of the interdisciplinary team. The goal of the nurse case manager is to facilitate provision of quality care across a continuum, decrease fragmentation of care across various settings, and contain costs.

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse? 1. "Would you mind answering the lights anyway?" 2. "I need you to answer the lights because we want to provide good client care." 3. Say nothing and answer the lights, but write up a disciplinary action 4. Tell the UAP that this is unacceptable and speak to the nurse manager

2. "I need you to answer the lights because we want to provide good client care." The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action. Educational objective:The nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats (aggression) and should not avoid the issue by just performing the action itself (avoidance).

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply. 1. 2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection 2. 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 3. A client in sickle cell disease crisis and a client with streptococcal pneumonia 4. A client who had abdominal surgery today and a client with universal precautions 5. A young client in Buck's traction with an elderly client with Parkinson's disease

2. 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 4. A client who had abdominal surgery today and a client with universal precautions 5. A young client in Buck's traction with an elderly client with Parkinson's disease When clients must be housed together in less than ideal circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly). Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious (even if this is not socially acceptable). Educational objective:Clients infected with different organisms cannot be placed together in the same room (due to risk of cross-infection). An infectious client should not be housed with an immunocompromised one.

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting

2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies clients who are safe to recommend for discharge to make room for newly admitted clients. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (Option 2). Educational objective:In response to a local disaster, the nurse identifies clients who can be safely discharged to make room for newly admitted clients. A client with acute asthma exacerbation can be safely discharged home when respiratory status has stabilized.

Which components are used in determining the standards of professional nursing practice? Select all that apply. 1. Care given with good intention to the best of one's ability 2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse Practice Act of the state or province/territory 5. Nurse's usual custom and practice

2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse Practice Act of the state or province/territory Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (Options 2, 3, and 4). Educational objective:The standards of professional nursing practice and care are defined by what reasonable, prudent nurses would do in specific circumstances. These are based on objective, third-party authoritative sources, including literature, laws (Nurse Practice Act), and professional organizations.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

2. Do the characteristics of the sample population match those of the nurse's unit? When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for adult clients with terminal cancer might not translate effectively or safely to those clients. Other aspects of the study to evaluate include whether all clinically relevant outcomes were addressed, if the benefits outweigh any potential harm or costs, and if the protocol resulted in improved care. Educational objective:When seeking to apply research findings in practice, the nurse should consider the similarities between the research study population and the client population.

The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospital's legal team 4. Report the incident to the state medical board

2. Document the exchange in the chart There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. (Options 1, 3, and 4) It is important to first refer up the nursing hierarchy. Educational objective:The nurse should document and then report objections about a clinician's judgment to the nursing supervisor.

Which issue would a unit quality improvement committee address? 1. A 10% decrease in client satisfaction in the registration process 2. A nurse who made 3 medication errors in the past quarter 3. An increase in catheter-associated urinary tract infections 4. Staff perception of hospital laboratory personnel incivility

3. An increase in catheter-associated urinary tract infections A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met. Examples requiring unit quality improvement include the following: Medications prescribed STAT are not available in a timely manner Catheter-associated bacterial infections are increasing within the unit (Option 3) Educational objective:A unit quality improvement committee assesses clinical issues arising on a unit (eg, increased infection rate) and problems with the systems and standards (eg, late delivery of medications from pharmacy) created to ensure delivery of quality care. This committee is not concerned with administrative or management issues (eg, client satisfaction surveys, individual performance reviews).

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply. 1. Acute head injury with Glasgow Coma Scale of 12 2. Admitted with cirrhosis of liver with oozing esophageal varices 3. Asthma exacerbation with peak flow at 85% of personal best 4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 × 109/L) 5. Myasthenia gravis with ptosis in the evening

3. Asthma exacerbation with peak flow at 85% of personal best 5. Myasthenia gravis with ptosis in the evening The best indication of moving air in a client with asthma is peak flow. The results are categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal best and caution), and red (<50% of personal best - a medical alert). This client is currently in good control. Other findings to note include effortless breathing, no cough or wheeze, and sleeping well all night (Option 3). Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness in skeletal muscles, especially in the bulbar region that involves eye movement, swallowing/speaking, and breathing. Such clients become more exhausted as the day progresses. The client can be discharged home as ptosis is an expected finding (Option 5). Educational objective:Clients with an acute head injury and a Glasgow Coma Scale of 12, thrombocytopenia while on heparin, or oozing varices in cirrhosis are not stable for discharge.

The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report? 1. Chest x-ray showed lung infiltrates; WBC count is 14,000/mm3 (14 x 109 /L) 2. Client's spouse was acting rudely toward the nurse earlier 3. Current respirations are 24/min; pulse oximetry is 93% on 2 L/min 4. Intravenous line is infusing with no signs of infiltration

3. Current respirations are 24/min; pulse oximetry is 93% on 2 L/min Current respiratory status is essential to include in handoff report, as it is objective information related to the client's current condition. Information communicated during report should allow the oncoming nurse to prioritize care and obtain baseline measurements of the client's current status and response to treatment. It is especially important to include information that may not be documented in the medical record. Respiratory status can change rapidly, and the most current measurements may not be documented, as vital signs are often documented every 4, 8, or 12 hours (Option 3). Handoff report typically includes: Client's name, location, age, gender, health care provider, and diagnoses Client's current baseline measurements, treatment plan, goals, and response to treatment Priority and outstanding tasks and changes from previous days Educational objective:Handoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record (eg, current respiratory status) so that the oncoming nurse can prioritize care.

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility 2. Nutritional consult with instructions on a high-calorie diet 3. Option of palliative care 4. Physical therapy prescription to promote activity

3. Option of palliative care This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. Educational objective:The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and symptom control and may eventually include hospice care based on the client's life expectancy.

After talking to the client, the health care provider (HCP) tells the registered nurse that the client's signature is needed on the consent form that has been filled out. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take? 1. Call the HCP to come and talk to the client 2. Refuse to witness the signature on the consent 3. Teach the client about a low-fat diet 4. Tell the client that the HCP will explain it later

3. Teach the client about a low-fat diet The HCP performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse's role. Educational objective:It is the HCP's responsibility to obtain informed consent and explain the procedure's risks, benefits, and alternatives to the client. The nurse can witness the client's signature and provide normal teaching. If the client has a question about the proposed procedure/surgery, the HCP should return and provide additional teaching.

A nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance? 1. The client will demonstrate proper organization of medications in a weekly pill box by the end of the teaching session. 2. The client will identify and attend a support group meeting for clients with dementia by the end of the month. 3. The client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session. 4. The client will verbalize 3 examples of easy, nutritious meals that can be prepared independently by the end of the clinic visit.

3. The client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session. Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to disease processes. This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future (Option 3). Educational objective:Anticipatory guidance addresses expected changes related to growth and development or disease progression. Educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client.

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? 1. Client with charred, leathery skin over entire back, chest, and legs 2. Client with cool skin, shivering from sitting in water until rescued 3. Client with diabetes who was unable to take prescribed insulin today 4. Client with high-pitched, crowing inspiratory respirations

4. Client with high-pitched, crowing inspiratory respirations Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high-pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4). Educational objective:During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply. 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level

4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia (Option 4). Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required (Option 5). Educational objective:ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin, gentamicin, amikacin) can cause nephrotoxicity.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? 1. Room 1 - client in skeletal traction following a fracture of the femur, who has erythema at the pin sites 2. Room 2 - client with cellulitis and osteomyelitis following blunt trauma of the tibia 3. Room 3 - client with compartment syndrome following a crush injury, who is 1 day post fasciotomy 4. Room 4 - client with a long leg cast following open reduction of a fractured tibia

4. Room 4 - client with a long leg cast following open reduction of a fractured tibia A client who is postoperative total knee replacement is at risk for infection. No postoperative client should be assigned to a room with a client who has an actual infection or the potential for infection. This client should be assigned to room 4 as the client with the cast has the lowest potential risk for infection (Option 4). Educational objective:A client who is postoperative total knee replacement is at increased risk for infection. This client should not be assigned to a room with a client who has an actual (eg, cellulitis, osteomyelitis) or potential (eg, skeletal traction, fasciotomy) infection.

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client? 1. Clinical psychologist 2. Occupational therapist 3. Physical therapist 4. Social worker

4. Social worker The case manager and social worker on the interdisciplinary team have expertise in discharge planning and health care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe, effective discharge planning. Educational objective:The nurse concerned about client safety at discharge should advocate for the client. Other interdisciplinary team members, such as the case manager or social worker, should be brought in to advocate for the client and explore alternate discharge resources or settings.

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? 1. Firmly indicate that the HCP cannot speak to the nurse in that manner 2. Immediately apologize and attempt to fix the situation 3. Say nothing and let the HCP vent frustrations 4. State that the conversation needs to take place in private and walk to a room

4. State that the conversation needs to take place in private and walk to a room When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference (eg, HCP/nurse). Rather than suggest and wait, the nurse should immediately leave and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concerns and work to resolve the issue (Option 4). Educational objective:The first response to public displays of disruptive behavior is to take action to make the conversation private.

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1. Encourage the night nurse to provide the UAP with additional training 2. Indicate that it is the night nurse's job to deal with staff problems 3. Remind the night nurse that the UAP is doing the best job the UAP can 4. Suggest that the night nurse discuss concerns with the nurse manager

4. Suggest that the night nurse discuss concerns with the nurse manager Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions (Option 4). Educational objective:When a caregiver's performance is below the standard of care needed to provide safe and quality care to clients, the appropriate authority should be notified so that the situation can be handled.

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence 2. The parent is in the process of a divorce and will soon be a single parent 3. The parent is witnessed stealing food and drinks from the cafeteria 4. The parent leaves the client's younger sibling to care for the client's newborn sibling

4. The parent leaves the client's younger sibling to care for the client's newborn sibling Child neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to fulfill the basic needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving children without adequate guardianship to ensure safety, is one form of child neglect (Option 4). Children age <12 lack formal operational reasoning and cannot anticipate safety risks or respond appropriately to emergencies, and should therefore not be left to supervise other children. It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social services, should report the situation to an appropriate government child protective service and/or law enforcement. Educational objective:Supervisory neglect (eg, leaving a young child to supervise other children) is a type of child neglect and represents an immediate risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to social services, the appropriate child protective service, and/or law enforcement.

Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site 2. Client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday 3. Client with atrial fibrillation and an irregular heart rate of 94/min 4. Client with dementia and Clostridium difficile (C difficile) who was incontinent of liquid stool

1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis (Option 1). Educational objective:To prioritize care, the nurse first identifies the type of problem, associated complications, and desired outcomes. The nurse then decides which client problems and needs are most urgent and require immediate action and which can be delayed.

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg/dL." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID. The Joint Commission (2004) and Institute for Safe Medication Practices prohibit error-prone or "dangerous" abbreviations, descriptions of symptoms, and dose designations in medical documentation. "Cm" (centimeters) and "II" (2) (eg, decubitus staging) are acceptable abbreviations/notations (Option 1). The abbreviations "ac" (before meals), "pc" (after meals), and "c/o" (complains of) are acceptable (Option 4). "QID" (4 times a day) is acceptable. Abbreviations that are not acceptable include "qd" (daily) and "q1d" (daily), which can be mistaken for "qid" (4 times a day), and "qod" (every other day), which can be mistaken for "qd" (daily) (Option 5). Educational objective:Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point.

The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and pulseless. The nurse calls the health care provider (HCP) at 2 AM, and the HCP begins to yell at the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is the best response by the nurse? 1. "I am concerned that this client may lose a leg unless something is done immediately." 2. "I am required to report all postoperative complications to the provider on call." 3. "It is my job to report critical findings, just like it is your job to come see my client right now." 4. "Yelling is unprofessional. I will need to file a report with my supervisor once the client is stable."

1. "I am concerned that this client may lose a leg unless something is done immediately." The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for clients. In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's needs, especially in situations that may result in client injury (Option 1). Educational objective:In response to unprofessional conduct, the priority is to shift the focus of the conversation back to the client's needs. After the client's needs are met, the nurse can take measures to address the unprofessional behavior (eg, filing a report).

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? 1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy 2. 6-year-old girl with varicella and 7-year-old girl with measles 3. 9-month-old boy with rotavirus infection and 8-month-old boy with salmonella infection 4. 14-year-old girl with sickle cell anemia and 13-year-old girl with periorbital cellulitis

1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given the options above, this is the safest room assignment. Educational objective:Pediatric room placement should be based on disease process, sex, and developmental stage. When assigning children to semi-private rooms, the charge nurse must consider client safety first.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. 1. Acting as a witness that the client signed the consent form voluntarily 2. Documenting in the medical record the date and time the signature was obtained 3. Educating the client if there is a misunderstanding about the procedure 4. Explaining to the client the right to refuse surgery 5. Verifying that the client is competent to provide informed consent

1. Acting as a witness that the client signed the consent form voluntarily 2. Documenting in the medical record the date and time the signature was obtained 5. Verifying that the client is competent to provide informed consent Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing (Options 1 and 5). The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature (Option 2). Educational objective:The nurse's role in informed consent is to witness a client's signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions.

The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? 1. Call the answering service and speak to the health care provider now 2. Document the results of the culture in the client's medical record 3. Leave a message on the health care provider's office phone 4. Speak to the health care provider on rounds in the morning

1. Call the answering service and speak to the health care provider now Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1). Educational objective:Critical laboratory results, such as positive blood cultures, require immediate communication with the health care provider (HCP) and timely

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply. 1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line 2. History of multiple sclerosis with ataxia and diplopia 3. One day postoperative from a hemicolectomy 4. Reporting abdominal pain with coffee ground emesis 5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value

1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line 2. History of multiple sclerosis with ataxia and diplopia 5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value. Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the control value demonstrates that warfarin has reached a therapeutic level. The long-term antibiotic course (and follow-up lab work) can continue at home through the PICC line (Options 1, 2, and 5). Educational objective:Those who are stable for discharge include the client with multiple sclerosis with ataxia and diplopia, the client on warfarin (Coumadin) that has reached the therapeutic effect, and the client with a PICC line for a long-term antibiotic course.

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. "I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset."

2. "I hope others will be helped through my involvement." Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and purpose of the study; confidentiality must be maintained. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation. Educational objective:Quantitative research studies involving humans must use ethical principles, including that the client cannot be coerced into participation and has the right to withdraw at any time.

Which client should the charge nurse assign to the room closest to the nurses' station? 1. Client with a Salem sump tube to continuous suction who is deaf 2. Client with gastroenteritis and dementia who wanders 3. Client with herpes zoster under airborne isolation precautions 4. Client with sickle cell crisis who requires frequent intravenous opioids

2. Client with gastroenteritis and dementia who wanders. The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room closest to the nurses' station as a confused client requires frequent checks and this allows the staff to respond quickly if necessary. Educational objective:When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety.

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan

2. Developed worsening cellulitis after missing antibiotics for 1 day 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury. The risk fall assessment should be adjusted. Option 5 is an avoidable delay in application of a test, which will affect timely diagnosis. The nurse should advocate for a more timely completion of the test. Option 2 is a failure to provide appropriate treatment and has a direct correlation for worsening cellulitis. Educational objective:Adverse events cause injury that is related to medical management, not the client's underlying condition. Identified areas are diagnostic, treatment, preventive or failure of communication, and equipment or other systems. Adverse events include falls, unreasonable delay in diagnostic tests, and failure to provide a prescribed treatment.

An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? 1. Call the telemetry unit manager 2. Notify the nursing supervisor 3. Send the client to ICU to "hold" the client in the hallway 4. Wait until the resident has time to request the transfer

2. Notify the nursing supervisor It is important to move the client to the ICU and for the ED to continue to care for incoming clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve interdepartmental issues when it is necessary for a higher authority to intervene and expedite processes (Option 2). Educational objective:A higher level of authority/chain of command, such as the nursing supervisor, should handle interdepartmental difficulties.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine

2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. Educational objective:A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis.

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager 2. Tell the HCP to stop the comments 3. Walk away and say nothing 4. Write up an incident report

2. Tell the HCP to stop the comments Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective, additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report, document, and support. Educational objective:A nurse who receives unwanted sexual advances in the workplace should first immediately and clearly indicate that the advances are unwanted and that the offending person should stop.

The nurse notifies the health care provider of a change in client condition. Which of the following reports given by the nurse includes the most appropriate and complete information? 1. "A 43-year-old client with pneumonia in room 343 has wheezing, crackles, and diminished breath sounds. Temperature is 101.2 F (38.4 C), respirations are 36/min, and pulse oximeter shows 90%. I think the client may need arterial blood gas testing." 2. "A 75-year-old client in room 474 is in respiratory distress. The respiratory therapist (RT) gave a breathing treatment, but the client is deteriorating rapidly. The RT did not hear left side breath sounds and recommends a chest x-ray." 3. "An 80-year-old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen flow rate?" 4. "The client with pneumonia in room 265 is reporting shortness of breath. The RT gave the client a breathing treatment 30 minutes ago, but the client is no better. Would you like to prescribe any laboratory tests or make any changes to the treatment?"

3. "An 80-year-old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen flow rate?" The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for communicating information about a change in client status to the health care provider (HCP). It includes the following information: S = Situation - what prompted the communication B = Background - pertinent information, relevant history, vital signs A = Assessment - the nurse's assessment of the situation R = Recommendation - request for prescription or action from the HCP The report given by the nurse in Option 3 contains the most appropriate and complete information. The nurse includes pertinent data related to history, admission, and present treatment (background); indicates when and what changes occurred (situation, assessment); and requests a prescription from the HCP (recommendation). Educational objective:Nurses commonly use the SBAR framework to report changes in client status to the health care provider, communicating the current situation, client background, nurse's assessment, and a recommendation for prescription or action.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) 3. Administered warfarin to a client with International Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

3. Administered warfarin to a client with International Normalized Ratio of 6 A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. Educational objective:The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and is occasionally 3.5. The risk of bleeding increases as the INR rises.

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action? 1. Ask the UAP to take the postoperative client's vital signs and report back immediately 2. Direct the UAP to ask the client to rate the pain on a scale of 0-10 and report back immediately 3. Direct the UAP to tell the client that you will be there shortly, and complete the sterile dressing change 4. Interrupt the dressing change to medicate the postoperative client

3. Direct the UAP to tell the client that you will be there shortly, and complete the sterile dressing change The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option 3). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option 4). Educational objective:A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait.

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client? 1. Room A: Client with multiple myeloma who is being treated with corticosteroids 2. Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics 3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube 4. Room D: Client with influenza with a high fever who is receiving oseltamivir

3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube Surgical debridement of an unstageable pressure injury involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A and B (Option 3). Educational objective:A client undergoing an extensive surgical debridement for an infected pressure injury should not be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or who has an active infection.

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly? 1. Ranitidine 150 mcg daily by mouth 2. Ranitidine 150 mg per os qhs 3. Ranitidine 150 mcg po qd nightly 4. Ranitidine 150 mg PO at bedtime

4. Ranitidine 150 mg PO at bedtime The nurse has correctly transcribed the prescription using approved abbreviations and standard terminology. Educational objective:Using approved abbreviations when transcribing health care provider prescriptions promotes client safety and prevents potential medication administration errors. Common abbreviations (per os, qhs, qd) can result in errors and should not be used.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS use

1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. Educational objective:The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on personal opinion or staff activities.

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? 1 "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems." 2. "I will talk with the HCP about your concerns, but in the meantime it's important that you stay here." 3. "It's important that you stay in the hospital so that we can treat you quickly if you have problems. 4. "You have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now."

1 "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems." When clients are hospitalized, they lose control of many things, including their medication management. This loss of control can be frightening for the client, especially one who has had control of medications for many years. This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed. Care planning should be a collaborative, shared process informed by the knowledge and preferences of the client and evidence-based recommendations by the HCP that are appropriate to the situation. Educational objective:A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs, and preferences, and the expertise and evidence-based recommendations of HCPs.

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply. 1. "A continuous IV heparin infusion was initiated at 18 units/kg/hr at 0800, and the infusion bag will need to be replaced at 2100." 2. "I gave acetaminophen 500 mg PO to the client for a headache, with good relief." 3. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 4. "The client's sisters visited today and were very rude, but they did bring the client's medication list." 5. "The radiology department called to say that an ultrasound will be performed at 2100."

1. "A continuous IV heparin infusion was initiated at 18 units/kg/hr at 0800, and the infusion bag will need to be replaced at 2100." 3. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 5. "The radiology department called to say that an ultrasound will be performed at 2100." A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: Provide identifying information (eg, client's name and room number). Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option 1). Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3). Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5). Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation). Educational objective:Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care priorities and upcoming or outstanding tasks; exact, pertinent information; multidisciplinary plans; and significant client changes.

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply. 1. 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 2. 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair 3. 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours 4. 2 UAPs using the log-rolling technique to move a client with a cervical collar 5. 3 UAPs using a draw sheet to move a client who weighs 220 lb (100 kg) up in bed

1. 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 4. 2 UAPs using the log-rolling technique to move a client with a cervical collar Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option 4). The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required (Option 1). Educational objective:Client repositioning and transferring can be delegated to unlicensed assistive personnel if it is deemed safe and appropriate. The nurse must provide instructions to maintain client safety and intervene if the task is performed inappropriately or requires nurse involvement (eg, spinal cord stabilization).

The charge nurse is reviewing clients' medical records on the cardiovascular care unit. Which client care outcomes are appropriate? Select all that apply. 1. Client receiving a continuous heparin infusion for a deep venous thrombosis remains free of petechiae or purpura 2. Client who had a carotid endarterectomy maintains a heart rate <100/min and blood pressure >90/60 mm Hg with no neurological changes 3. Client who had a percutaneous coronary intervention maintains a chest pain level of <4 on a scale of 0-10 while at rest 4. Client with hypertension receiving IV furosemide remains free from muscle cramping in the extremities 5. Client with peripheral arterial disease following a femoral-popliteal angioplasty remains free of leg pain during ambulation

1. Client receiving a continuous heparin infusion for a deep venous thrombosis remains free of petechiae or purpura 2. Client who had a carotid endarterectomy maintains a heart rate <100/min and blood pressure >90/60 mm Hg with no neurological changes 4. Client with hypertension receiving IV furosemide remains free from muscle cramping in the extremities 5. Client with peripheral arterial disease following a femoral-popliteal angioplasty remains free of leg pain during ambulation Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg, petechiae, purpura) (Option 1). Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status) (Option 2). Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac arrhythmia) (Option 4). A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia (eg, leg pain) (Option 5). Educational objective:Clients receiving heparin should remain free from heparin-induced thrombocytopenia. After carotid endarterectomy, clients should remain free from hemorrhage and neurological impairment. Those receiving loop diuretics should maintain electrolytes within normal limits. After a femoral-popliteal angioplasty, clients should be able to ambulate without leg pain. They should have no chest pain at rest after a percutaneous coronary intervention.

After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)

2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. Educational objective:The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPAA 5. Teach about one intervention at a time and in the order it will occur

2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 5. Teach about one intervention at a time and in the order it will occur Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5). Educational objective:When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply. 1. Client has a row of 3-inch circles down the back from "cupping" 2. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA) 3. RN thinks a teenage client's signs are from abuse, but the health care provider does not 4. RN thinks an elderly client's signs are from abuse but the client denies this 5. Syphilis is diagnosed in an 11-year-old who denies sexual activity

2. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA) 3. RN thinks a teenage client's signs are from abuse, but the health care provider does not 4. RN thinks an elderly client's signs are from abuse but the client denies this 5. Syphilis is diagnosed in an 11-year-old who denies sexual activity The RN is required to report suspected abuse of vulnerable clients (eg, underage, elderly, mentally ill) to appropriate authorities, regardless of what other practitioners think. A proper investigation, rather than conflicting opinions, will determine whether abuse has occurred (Option 3). The RN should report suspected abuse of vulnerable clients even if the client denies it because other factors (eg, dependence on the abuser, dementia) could be the reason for denial (Option 4). Sexually transmitted infection (STI) in a child is sexual abuse and must be reported and investigated (Option 5). The greater good of society outweighs an individual's right to confidentiality. Gonorrhea is an STI; the client should be informed that public health will be notified and partners will be contacted to receive treatment (Option 2). Educational objective:An RN is required to report suspected abuse of vulnerable clients even if other practitioners do not agree or the clients deny it. An STI in a child is considered sexual abuse and requires reporting. Reportable conditions by law are not protected from reporting under the confidentiality of personal health care information in HIPAA.

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need surgery?" What is the most appropriate action? 1. Call the nursing supervisor 2. Call the operating room scheduler and cancel the surgery 3. Page the health care provider and request clarification on behalf of the client 4. Report the incident to hospital administration

3. Page the health care provider and request clarification on behalf of the client Informed consent requires that the health care provider performing the procedure explain everything to the client's satisfaction (within reason). Signed consent may be witnessed by the nurse. If the client does not fully understand informed consent, the nurse must notify the health care provider or refer up the chain of nursing command. The nurse is not responsible for verifying that the client understands the procedure and its respective risks. Educational objective:Clients may not consent to an invasive procedure without being informed of the clinical reasoning, consequences, and possible complications.

The nurse calls the health care provider at midnight and states, "Client X in room 212 had a colectomy yesterday and is now lethargic. The client currently has a rising pulse at 130/min and a falling systolic blood pressure at 80 mm Hg. I am concerned that the client is going into shock." With regard to the SBAR (Situation, Background, Assessment, and Recommendation/Request) communication technique, what is the most important information excluded by the nurse? 1. Basic demographic information 2. Current temperature and trend 3. Requesting action by the health care provider 4. Significant past medical history and allergies

3. Requesting action by the health care provider SBAR has been updated in some facilities to I-SBAR-R (Introduction, Situation, Background, Assessment, Recommendation/Request, and Read-back). This communication technique is a framework to provide essential information in an organized fashion. It is recommended by the Joint Commission and is especially useful when a client's condition is changing rapidly. In this case, the nurse has omitted the Recommendation/Request of SBAR when communicating with the health care provider (HCP). Examples of appropriate recommendations include asking the HCP to see the client, perform a diagnostic test, request a consultation, or prescribe IV fluid administration. Educational objective:SBAR (or I-SBAR-R [Introduction, Situation, Background, Assessment, Recommendation/Request, and Read-back]) is used to communicate pertinent information regarding changes in a client's condition in an organized fashion. The content should include the situation (why the nurse is calling), background, assessment, and a recommendation/request of the health care provider.

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggests the transfer of which client to the health care provider? 1. 52-year-old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels 2. 60-year-old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem 3. 65-year-old admitted last night for third-degree heart block who is awaiting permanent pacemaker placement 4. 78-year-old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

4. 78-year-old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any health care setting. Educational objective:Clients with unstable angina experiencing chest pain and clients newly admitted with complete heart block or atrial fibrillation with a rapid ventricular response are unstable and require continual monitoring in an intensive care unit.

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment? 1. Adult protective services 2. Physical therapist 3. Physician 4. Social worker

4. Social worker An important part of the nursing role is to advocate for the health and safety of the client. This client has fallen and lost weight when living in the child's home, prompting the nurse to advocate for the client by bringing in other members of the interdisciplinary team to assess the home situation. When a nurse is concerned about the client's living situation, the social worker is the most appropriate team member to consult with first. The role of the social worker includes assessing the client's living situation and arranging for an alternate living situation or support services as needed. Educational objective:Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as the social worker. Advocacy is especially important in younger and elderly clients and those who are cognitively challenged or have mental health concerns.

The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate registered nurse (RN) during orientation. The LPN states, "The only difference between you and me is the size of our paychecks." What would be the best response for the new graduate RN to make initially? 1. Assert being the manager of the client team 2. Emphasize the additional education received 3. Explain the legal difference in the scope of practice 4. Focus on the need to work together for quality client care

4. Focus on the need to work together for quality client care Team building involves recognizing that everyone has personal strengths and specific skill sets that together can be used to provide quality client care. The new graduate should recognize the contributions of the LPN and give respect to the LPN rather than initially be confrontational. Emphasizing common goals, such as safe, quality client care, is usually more effective than debating personnel qualifications. Educational objective:When initially confronted by other team members about qualifications or experience, the RN should emphasize the common goal of working toward safe, quality client care.

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers? 1. Decreased length of hospital stay 2. Less obvious needs of clients met accordingly 3. Properly educated clients 4. Reduced number of medical errors

4. Reduced number of medical errors Miscommunication between health care providers may cause serious medical errors when clients are handed off or transferred. Medical errors can be effectively reduced by employing strategies (eg, Situation, Background, Assessment, and Recommendation [SBAR] reporting technique, nurse-to-nurse change of shift reports, multi-professional bedside rounds) to improve communication and collaboration. Nurses should be as proficient in their communication skills as they are in their clinical skills. Educational objective:Effective communication among caregivers is necessary to deliver safe client care and reduce the number of medical errors.

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases 2. Give the parents written instructions with picture illustrations 3. Tell the parents to have a friend or relative come in to translate 4. Use an interpreter via the telephone interpretation service

4. Use an interpreter via the telephone interpretation service Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option 4). Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. When a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially in situations where sensitive information needs to be communicated (Option 3). Children should not be used as translators except in an emergency situation when there are no other options. Educational objective:When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes.

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

1. Document the interactions with the bully 3. Observe interactions between the bully and other colleagues 5. Tell the bully you will not tolerate the unprofessional behavior Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague. These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral violence. Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include: Documenting and keeping a file of all incidents (Option 1) Reporting the incidents to the immediate supervisor Letting the bully know that the behavior will not be tolerated (Option 5) Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) (Option 3) Seek support from within the facility or from an external source Educational objective:Lateral violence in the workplace (acts of aggression by an employee toward another employee) should not be tolerated or ignored. Victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way, and seeking support.

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying a new dressing, when sterile technique is commonly used). The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it wet, do not reach over it). Educational objective:Use clean, rather than sterile, gloves when removing contaminated dressings. The inside of a sterile glove wrapper is sterile. Do not return items in clients' rooms to central supplies, discard sterile solution after 24 hours, and do not reuse tourniquets between clients.

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? 1. Assess for copious secretions to determine exposure 2. Assist the victims farthest from the source first 3. Assist the victims with the most severe symptoms first 4. Monitor for diplopia to determine extent of exposure

2. Assist the victims farthest from the source first The key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. Educational objective:In triaging victims from a radiation contamination disaster, nurses should assist clients who are farthest away from the source and have the least symptoms as most damage is internal and will not be apparent initially. Nerve agents (eg, sarin) cause excess acetylcholine with copious secretions. Neurologic symptoms are classic for biological threats such as botulinum toxin.

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? 1. Ask if the client can go without the oxygen for 2 hours 2. Delay discharge until the oxygen is delivered 3. Notify the health care provider (HCP) to see what action should be taken 4. Send a hospital oxygen tank home with the client

2. Delay discharge until the oxygen is delivered The nurse (with the case manager) needs to assure that the client has the essential equipment/supplies for a smooth discharge into the home environment. The safest option is to delay discharge until that can be accomplished. Educational objective:A client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge.

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply. 1. "Occupational therapy will help me learn how to properly use my walker." 2. "Physical therapy will help me learn how to dress myself again." 3. "Social services can help me find resources for affording my medications." 4. "Speech therapy will teach me how to eat my meals properly." 5. "Wound care will teach me how to properly dress this wound on my knee."

3. "Social services can help me find resources for affording my medications." 4. "Speech therapy will teach me how to eat my meals properly." 5. "Wound care will teach me how to properly dress this wound on my knee." Several adjunctive professional services assist clients in the post-acute phase of their illness as part of an overall interdisciplinary team. Speech therapy focuses on speech and communication but also on swallowing/eating issues (Option 4). A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-down positioning, chewing on the non-affected side of the mouth). Social workers assist with developing coping skills, securing adequate financial resources or housing, and making referrals to volunteer organizations (Option 3). Wound care is a resource for assessing and planning the optimal care of any wound (Option 5). Educational objective:Some of the adjunctive professional services in post-acute care include wound care (eg, assessing/planning wound treatment), speech therapy (eg, communicating, swallowing, eating), social work (eg, coping, connecting to resources), physical therapy (eg, mobility, ambulating, using equipment), and occupational therapy (eg, activities of daily living).

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially? 1. Discuss the need for UAP inservice education with the nurse manager 2. Give praise to the UAP for encouraging the client to walk the entire hall 3. Immediately lower the bag and speak privately to the UAP 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift

3. Immediately lower the bag and speak privately to the UAP The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client. Educational objective:When observing a provider making an error, correct it immediately to stop any potential harm to the client. Correct the provider privately and as soon as possible.

A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Client at 8 weeks gestation with spotting and pulse of 90/min 2. Client with a compound femoral fracture and an oozing laceration 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with paradoxical chest movement throughout respirations

4. Client with paradoxical chest movement throughout respirations Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4). Educational objective:During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center

4. Reporting in to the local command center Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: Clients may not know where or how to seek help Clients may be afraid or unable to leave their homes Telephone services and other lines of communication may be disrupted Potential clients may leave their homes and go to shelters or alternate housing Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments. Educational objective:Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts.

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? 1. UAP applies the anti-embolism stockings while maintaining the client in supine position 2. UAP carefully smoothes out any wrinkles over the length of the stockings 3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot 4. UAP rolls down and folds over the excess material at the top of the stockings

4. UAP rolls down and folds over the excess material at the top of the stockings Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn consistently, the stockings decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded. Educational objective:Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the nurse verifies the stockings are correctly fitted and worn appropriately. Incorrect size and fit or alterations to the stockings can impede venous return.

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse? 1. Explain that the client's depression is being treated with medications 2. Explain that the client's depression will not be relieved by a ritual 3. Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony 4. Tell the family that such practices are not allowed in the hospital

3. Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony The medicine healer, or shaman, is an important component of Native American culture and is often consulted by both clients and HCPs when a client is ill or hospitalized. The medicine healer uses a variety of practices, including herbs, plants and roots, singing, and healing ceremonies. The medicine healer needs to be included in this client's treatment. Making arrangements for the healing ritual gives credibility and respect to the client's cultural beliefs and ensures that the client's spiritual needs will be met. In providing culturally sensitive care, the nurse needs to recognize and be tolerant of various practices associated with beliefs that are different from those of traditional Western medicine. Denying the medicine healer the opportunity to perform a ritual could interfere with the client's response to therapy. Educational objective:Medicine healers, or shamans, are an important component of Native American and other cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that clients' spiritual needs are met and may contribute to the healing process. The nurse needs to recognize and be tolerant of health practices and beliefs that are different from those of traditional Western medicine.

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1. A client diagnosed with varicella and a client with pertussis 2. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis

4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option 4). Clients with the same organism can room together (Option 5). Educational objective:For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients.

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1. Room 1 - Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL (14.7 mmol/L) 2. Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 (0.2 x 109/L) 3. Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4. Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/L)

4. Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/LThe best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Educational objective:An immediate post-operative client should not be assigned a bed in a room with a client who is contagious or potentially infected as this poses an increased risk for infection.

The nurse is caring for a client with chronic pain who just had surgery and is receiving patient-controlled analgesia (PCA) morphine. The client is in severe pain, with a rating of 10/10, despite receiving the maximum ordered dose. The nurse calls the health care provider, saying that the client is still having pain and recommending a higher PCA dose. Which nursing role is being implemented in this situation? 1. Advocate 2. Caregiver 3. Educator 4. Manager

1. Advocate The role of the nurse as advocate is to protect the rights of the client, including the right to adequate pain control. The nurse acting as advocate speaks up for clients when they cannot easily speak for themselves. Educational objective:An important nursing role is client advocacy, which involves speaking up for clients to protect their rights and improve their health outcomes and experiences.

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? 1. Ask a client if the UAP has performed the test 2. Discuss the importance of task completion and accurate documentation in a staff meeting 3. Give the UAP a verbal warning not to falsify data 4. Take a client's capillary glucose personally and compare it to the recorded result

4. Take a client's capillary glucose personally and compare it to the recorded result The best initial result is to assess and validate the charge nurse's perception. Doing the test and comparing results randomly/intermittently will give data to prove/disprove this concern. Educational objective:When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which is the most appropriate action by the nurse? 1. Act as a witness for the informed consent process 2. Provide additional information about what the client can expect 3. Report the surgeon to the ethics board for using an inappropriate consent process 4. Talk to the surgeon privately about using a trained Spanish-language medical interpreter

4. Talk to the surgeon privately about using a trained Spanish-language medical interpreter The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. The person interpreting for the client should ideally possess the following: Training in medical terminology and procedures Ability to protect the client's rights in a medical setting Fluency in the language Understanding of cultural beliefs and nuances For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and a family member is the only one available to fill this role. Educational objective:The nurse acting as a client advocate should ensure the appropriate use of medical interpreters to promote adequate client understanding and participation in the decision-making process. This is particularly important during the informed consent process.