NU470 Week 7 PrepU: Collaboration/Teamwork & Collaboration

A nurse working in a primary health care facility would most likely provide which service? o Screening o Treatment o Acute care o Rehabilitation

o Screening · Screening falls within the category of primary health care. Acute care and treatment are a part of secondary health care. Rehabilitation falls under tertiary health care.

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success? o Caregiver o Coordinator o Nurse practitioner o Clinician

o Coordinator · Discharge planning is most successful when it is done in collaboration with the client and family, not for them. The discharge planner or coordinator is the health or social services professional who is responsible for coordinating the transition and serving as a link between the discharging facility and the community. A nurse practitioner is an advanced clinician who prescribes medications and provides care. A clinician is a physician having direct contact with and responsibility for clients. A caregiver is a family member or paid helper who regularly looks after a child or a person who is sick, older, or disabled.

Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client? o Caregiver o Care coordinator o Advocate o Educator

o Educator · The home healthcare nurse provides teaching, such as demonstration of a skill, to the family as a client educator. The home healthcare nurse develops and implements the plan of care in the caregiver role, such as obtaining a sputum specimen. As a client advocate, the home healthcare nurse protects and supports the client's rights. The home healthcare nurse coordinates direct care to the client and services of other healthcare providers.

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider? o K+ 3.1 mEq/L o Na+ 140 mEq/L o Mg++ 2 mEq/L o Ca++ 9 mg/dL

o K+ 3.1 mEq/L · All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.

The client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client? o Social worker o Occupational therapist o Physical therapist o Home health aide

o Occupational therapist · The occupational therapist can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as cooking. The physical therapist provides direct care, such as muscle-strengthening exercises, gait training, and massage. The home health aide assists clients with hygiene and performing light housekeeping. The social worker provides assistance with health care finances and in securing equipment and supplies.

The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? o To analyze the lymph nodes involved o To remove the tumor from the brain o To prevent the formation of new cancer cells o To destroy marginal tissues

o To prevent the formation of new cancer cells · Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present; also, it can be used prophylactically to prevent spread. Biopsy is used to analyze lymph nodes or to destroy the surrounding tissues around the tumor.

A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? o Explain that cardiac catheterization does not involve open heart surgery, and then medicate the client. o Withhold the medication and cancel the procedure. o Medicate the client and document his comment. o Withhold the medication and notify the physician immediately.

o Withhold the medication and notify the physician immediately. · The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, there cannot be a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent.

Kaposi sarcoma (KS) is diagnosed through o skin scraping. o biopsy. o computed tomography. o visual assessment.

o biopsy. · KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? o Glucocorticoids o Nonsteroidal anti-inflammatory drugs (NSAIDs) o Disease-modifying antirheumatic drugs (DMARDs) o Tumor necrosis factor (TNF) blockers

o Disease-modifying antirheumatic drugs (DMARDs) · Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.

The nurse is caring for a child who receives dialysis via an AV fistula. Which finding indicates an immediate need to notify the physician? o presence of a thrill o absence of a thrill o presence of a bruit o dialysate without fibrin or cloudiness

o absence of a thrill · The nurse should always auscultate the site for presence of a bruit and palpate for presence of a thrill. The nurse should immediately notify the physician if there is an absence of a thrill. Dialysate without fibrin or cloudiness is normal and is used with peritoneal dialysis, not hemodialysis.

A male client diagnosed with bone cancer has an order for clonidine on his chart. The nurse is concerned that this may be a mistake and asks another nurse why clonidine would be ordered for this client. What would be an appropriate response from the second nurse? o "Clonidine is given for hypotension, so this client must have a history of hypotension." o "Clonidine decreases cancer cells within the bone so the provider ordered it for that reason." o "Clonidine is sometimes prescribed for severe pain in cancer clients like this client." o "Clonidine will not hurt him, so follow the order."

o "Clonidine is sometimes prescribed for severe pain in cancer clients like this client." · Clonidine is prescribed to treat severe pain in clients with cancer. Clonidine does not have an effect on cancer cells. A nurse should not blindly follow orders. Clonidine is given for hypertension, not hypotension.

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following? o "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." o "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." o "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers." o "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node."

o "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." · The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

The nurse receives a telephone call from a client with an implanted pacemaker who reports a pulse of 68 beats per minute, but the pacemaker rate is set at 72 beats per minute. What is the nurse's best response? o "Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." o "This is okay as long as you are not having any symptoms." o "Don't worry. The pacemaker's rate is often higher than the client's actual heart rate." o "Try walking briskly for about 5 minutes to see if that gets your heart rate to increase."

o "Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." · A client experiencing pacemaker malfunctioning may develop bradycardia as well as signs and symptoms of decreased cardiac output. The client should check the pulse daily and report immediately any sudden slowing or increasing of the pulse rate, which may indicate pacemaker malfunction. The client needs to be evaluated to avoid cardiac output problems. Walking will not keep the heart rate at a safe level.

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse prepares the client according to the anesthetist's instructions. Which statement by the anesthetist would the nurse question? o "Hold the client firmly in position while I administer the spinal block." o "Obtain a set of vital signs, and connect the client to a continuous oxygen saturation monitor." o "Review the client's current medications, and verify the last dose of anticoagulants." o "Position the client supine on the operating table, and prepare the site for injection."

o "Position the client supine on the operating table, and prepare the site for injection." · The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and to ensure proper anesthetic distribution. The nurse would assist the client in a sitting or lateral position; lying supine is inappropriate as it obstructs the site of injection. Reviewing and verifying the last dose of anticoagulants will alert the nurse to a risk for bleeding. Obtaining vital signs is important to get baseline readings for comparison during and after the procedure. Since respiratory paralysis is a complication of subarachnoid injections, continuously monitoring the client's oxygen saturation is an appropriate intervention. Asking the nurse to hold the client firmly during the procedure will prevent sudden client movement that may displace the needle and cause injury to the nerve root.

A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation? o "The client began complaining of severe chest pain, rating it as a 10 on a scale of 1 to 10, after walking back from the bathroom." o "This event seemed to come out of the blue. The client denies any history of heart disease but does take a baby aspirin each night." o "The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." o "The client had an exploratory laparotomy 2 days ago and was progressing well. The vital signs were stable until this episode."

o "The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." · SBAR provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of client safety. S stands for the situation (complaint, diagnosis, treatment plan, and client's wants and needs); B stands for background (vital signs, mental and code status, list of medications, and lab results); A stands for assessment (current provider's assessment of the situation); and R stands for recommendations (identification of pending lab results and what needs to be done over the next few hours, along with other recommendations for care).

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? o 13 to 18 o 1 to 2 o 6 to 12 o 3 to 5

o 6 to 12 · Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. 6 to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

A nurse is preparing to make a home visit to a family. Which of the following would the nurse need to keep in mind as most reflective of a family? o A group of individuals related by blood or marriage o Several generations involved in providing physical and emotional support to one another o A husband, wife, and children living under the same roof o A group related by reciprocal caring, mutual responsibilities, and loyalties

o A group related by reciprocal caring, mutual responsibilities, and loyalties · Family refers to a group of individuals who are related by reciprocal caring, mutual responsibilities, and loyalties. It is more than the relationship by blood or marriage and may or may not involve a spousal, parent-child, or multigenerational relationship.

Two nurses are having a disagreement over who will take the next admission to the unit. The nurse manager asks one of the nurses to take the admission and explains that this will be considered a personal favor. Which style of conflict resolution did the nurse manager display? o Collaborating o Avoiding o Competing o Accommodating

o Accommodating · The nurse manager is displaying a conflict resolution style of accommodating by asking one of the nurses to accept the assignment of the admission. If the nurse manager had ignored the situation, this would have been the avoiding style of conflict resolution. With a competing style, the nurse manager would have told the nurse to accept the admission, rather than asking the nurse. If collaborating is the conflict resolution style used, the nurse manager would have discussed the situation with both nurses in order to achieve a solution to this conflict.

A client has been diagnosed with an infected postoperative wound, and cultures reveal methicillin-resistant Staphylococcus aureus (MRSA). The client is currently receiving intravenous ceftaroline because in vitro testing indicates susceptibility. When considering the effectiveness of this client's treatment, what is the nurse's best action? o Administer the medication as prescribed and monitor for expected outcomes. o Monitor the client closely for signs of hepatotoxicity. o Contact the health care provider because the medication is not known to be clinically effective. o Contact the health care provider because the medication should be changed to the oral route.

o Administer the medication as prescribed and monitor for expected outcomes. · The nurse's responsibility in supporting prescribed medication therapy is to administer the medication as prescribed and to monitor for expected outcomes. Ceftaroline is an IV cephalosporin used for the treatment of community-acquired pneumonia and skin infections. It is the first cephalosporin to be considered active against resistant gram-positive organisms, such as MRSA, vancomycin-resistant S. aureus (VRSA), vancomycin-insensitive S. aureus (VISA), and heteroresistant VISA. Decreased renal function, not hepatic function, is a prescribing concern.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits o Troponin levels less than 0.35 ng/mL o Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute o Adventitious breath sounds o A change in apical pulse rate from 102 to 88 beats/min

o Adventitious breath sounds · The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

The new nurse is evaluating the effectiveness of the assigned nurse mentor. Which characteristic should the new nurse recognize as being inappropriate for the nurse mentor to role model? o Introducing the new nurse to members of the interdisciplinary team o Providing daily feedback to the new nurse o Encouraging the new nurse to enroll in continuing education courses o Advising the new nurse to consult the nurse mentor before making decisions regarding client care

o Advising the new nurse to consult the nurse mentor before making decisions regarding client care · Effective mentors should provide feedback to the mentee, encourage opportunities for continued growth, and provide resources that will be supportive in the new role of nurse, including members of the interdisciplinary team. Effective mentors should promote confidence in the new nurse in the decision making process. Requiring the new nurse to report to the nurse mentor before making decisions can hinder the new nurse's confidence level.

Degree of agreement between the leader's norms and the group's norms, ability to deal with members' infractions, and conformity to group norms are characteristics of what kind of groups? o Secondary groups o All groups o Formal groups o Primary groups

o All groups · A group is three or more people with related goals. The following characteristics vary among different types of groups: size, homogeneity or heterogeneity of members, stability, degree of cohesiveness among members, climate, conformity to group norms, degree of agreement with the leader's and the group's norms, ability to deal with members' infractions, and goal-directedness and task orientation of the group's work.

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? o Arrange a meeting between the health care team and the parents to develop a care plan. o Help the parents schedule a follow-up appointment with the pediatrician before discharge. o Ask the community health nurse to visit the family. o Provide written care instructions for the parents.

o Arrange a meeting between the health care team and the parents to develop a care plan. · A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.

Which is not a cognitive or sensory deficit? o Substance Abuse o Chronic severe pain o Dementia o Asthma

o Asthma · Asthma should not hinder the client's ability to live independently as chronic severe pain, dementia, or substance abuse would.

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation? o Coercive o Laissez-faire o Authoritarian o Democratic

o Authoritarian · With authoritarian, or autocratic, leadership, the leader determines, dictates, and directs the activities of the group, with no input from the followers on decisions. It is particularly effective when decisions for a large group need to be made quickly and efficiently, as in this scenario. Coercion--involving forcing actions upon the staff--is not a recognized leadership style and, in any case, would not be an advisable approach as it would likely trigger resistance in the group and be counterproductive. Democratic leadership is appropriate when the task, or decision at hand, is not one that requires urgent action, when subordinates can be expected to make meaningful contributions, and when their input can be taken into account. Laissez-faire management provides little or no direction; coworkers develop their own goals, make their own decisions, and take responsibility for their own management.

Following the injection of a prescribed vaccination, a client has injected antibodies circulating through the body. The nurse explains the client's body will respond in what manner? o Be able to respond to the presence of antigens more quickly. o Experience active immunity. o Develop serum sickness. o Form an immune response to the circulating antibodies.

o Be able to respond to the presence of antigens more quickly. · The circulating antibodies act in the same manner as those produced from plasma cells, recognizing the foreign protein (antigen) and attaching to it, rendering it harmless. The immune system responds to antigens, not antibodies. Serum sickness is an atypical response involving antibodies against antibodies.

The nurse is preparing to administer a mixture of 12 units regular insulin and 45 units NPH insulin to a client with a blood sugar of 378 mg/dL. After the nurse draws the medication into the syringe, what is the nurse's next action? o Check the dosage with another nurse. o Ensure a meal tray is available. o Administer the insulin to the client. o Check the client's blood sugar again.

o Check the dosage with another nurse. · After preparing the syringe with insulin, the nurse should then have the medication and dosage checked by a second nurse to make sure that it is correct. It is not necessary to recheck the client's blood sugar again. It is important to know when the client will be eating again; make sure that it is within the next 30 minutes. However, this is not the nurse's next step. Then the nurse will administer the insulin to the client.

Which statement is inconsistent with the concept of milieu therapy, originally developed by Henry Stack Sullivan? o The therapy incorporates a safe, therapeutic setting. o Clients work independently to solve day-to-day problems. o The therapy enables clients to give one another feedback about behavior. o The therapy includes the practice of interpersonal relationship skills.

o Clients work independently to solve day-to-day problems. · The concept of milieu therapy, originally developed by Sullivan, involved clients' interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? o Question the woman in front of her partner. o Contact hospital security to escort the partner from the hospital. o Collaborate with the physician to make a referral to social services. o Tell the partner that to leave because the partner is intimidating the client.

o Collaborate with the physician to make a referral to social services. · Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her partner does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.

A client is brought to the emergency department with a head injury following an all-terrain vehicle (ATV) accident. The nurse asks the family members to describe how the accident occurred. The nurse is implementing which ANA standard? o Education o Evaluation o Collaboration o Diagnosis

o Collaboration · According to the ANA Standard 13 - Collaboration, the registered nurse collaborates with the client, family, and others in the conduct of nursing practice. Standard 2 - Diagnosis states that the registered nurse analyzes the assessment data to determine the diagnoses or issues. Standard 6 - Evaluation states that the registered nurse evaluates progress toward attainment of outcomes. Standard 8 - Education pertains to the registered nurse attaining knowledge and competence that reflects current nursing practice.

After one week in the hospital for chemotherapy treatment related to lymphocytic leukemia, a client develops abdominal pain, fever, and foul-smelling diarrhea. What priority recommendation does the nurse make to the healthcare provider? o Prescribe STAT intravenous fluid therapy. o Collect stool sample for Clostridium difficile. o Collect a sample for stool culture and sensitivity. o Prescribe an antidiarrheal medication.

o Collect stool sample for Clostridium difficile. · Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes foul-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. A stool culture and sensitivity does not test specifically for C. diff and is not recommended for clients who have been hospitalized for more than 3 days. The nurse should collect the sample and institute contact precautions prior to conducting further assessments related to fluid balance. The nurse would not request an antidiarrheal until the cause of the diarrhea is known.

A registered nurse (RN) is receiving an admission to the medical-surgical unit. Which nursing responsibilities would be appropriate to delegate to the licensed practical/vocational nurse (LPN/VN) on the unit? Select all that apply. o Collecting the IV pole and assessment equipment o Assisting a client with incentive spirometry o Contacting the health care provider and obtaining admission orders o Preparing the bed and room for the admission o Performing the initial physical assessment and vital signs

o Collecting the IV pole and assessment equipment o Assisting a client with incentive spirometry o Preparing the bed and room for the admission · The nurse must recognize the scope of practice in order to delegate. An LPN/VN can prepare the room, collect equipment, and assist clients with incentive spirometry under the LPN's Nurse Practice Act. An LPN/VN cannot do parts of the nursing process such as performing initial assessments or calling for admission orders. The ability of the LPN to perform some tasks, such as medication administration, can vary by state or province. Both the RN and LPN should understand the limits of what can be delegated.

A typical day for the nurse manager includes the time she spends with other nurses, client, physicians, and ancillary staff. The most important skill she must have is the ability to o Communicate with all groups o Provide direct client care o Plan for the future o Maintain the unit's budget

o Communicate with all groups · Communication, a prerequisite to problem solving, is one of the fundamental skills of management.

An informatics nurse specialist is working with a team to design a clinical information system. To ensure system usability, the team would make sure that the language meets which criterion? Select all that apply. o Conciseness o Jargon-like o Computer-based o Familiarity for the user o Clarity

o Conciseness o Familiarity for the user o Clarity · All language used in a clinical information system should be concise and unambiguous. Terminology used also must be familiar and meaningful to the end users in the context of their work; no terms related to computers, technology, HL7, databases, and so forth should appear in the user interface.

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose prescribed and the dose scanned. What is the nurse's most appropriate response? o Consult with a colleague and identify the source of the error signal before proceeding. o Administer the dose specified by the computer system and document the event. o Document the discrepancy and place the medication on hold until the next scheduled dose. o Consult the client's medication prescription and then administer the dose originally poured.

o Consult with a colleague and identify the source of the error signal before proceeding. · If an error message is received during medication administration, the nurse must be diligent in determining the reason for the message and correcting whatever is causing the error. It is not possible to say what the appropriate response would be until the nature of the discrepancy is identified. It would be prudent to enlist the help of a colleague to ensure the right decision is made. Administering the medication without clarification is as potentially unsafe as placing the medication on hold until the next scheduled dose.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? o Chart the information. o Consult with another nurse. o Call the family. o Wait and see whether the pain subsides.

o Consult with another nurse. · A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.

The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? o Organize a meeting between the chaplain, the son, and the client to achieve a resolution. o Document the client's request and wait to see if the client reiterates the request. o Perform a detailed spiritual assessment of the client. o Contact the chaplain to arrange a visit with the client.

o Contact the chaplain to arrange a visit with the client. · The nurse's primary responsibility is to honor the client's request for a meeting with a spiritual advisor. Completing a spiritual assessment is not necessary at this time. Organizing a meeting between the chaplain, the son, and the client is not an accurate intervention at this time unless requested by the client. Documentation of the conversation with the client and calling for a spiritual advisor should be recorded in the client's health record. It is not necessary to document and wait for the client to ask again before the nurse considers the request. Afterall, she is dying and waiting for her to ask again is not warranted.

A nurse is evaluating a client's morning laboratory values. Which result requires that the nurse notify the health care provider? o Potassium: 3.4 mEq/L (3.4 mmol/L) o Creatinine: 10.6 mg/dL (937.04 µmol/L) o Blood urea nitrogen: 20.0 mg/dL (7.14 mmol/L) o Sodium: 148 mEq/L (148 mmol/L)

o Creatinine: 10.6 mg/dL (937.04 µmol/L) · A rise in the serum creatinine level to three times its normal value suggests that there is a 75% loss of renal function, and with creatinine values of 10 mg/dL or more, it can be assumed that approximately 90% of renal function has been lost.

Nursing practice consistent with the Code of Ethics for Nurses includes which actions? Select all that apply. o Assuming responsibility for care with limited collaboration with other healthcare professionals o Delivering culturally safe care o Empathizing with clients and establishing friendships when appropriate o Protecting the client's right to confidentiality and privacy o Acknowledging that the client is the focus and center of care and remains a part of the treatment team

o Delivering culturally safe care o Protecting the client's right to confidentiality and privacy o Acknowledging that the client is the focus and center of care and remains a part of the treatment team · Nurses should always deliver culturally safe care, as well as protect the client's right to confidentiality and privacy in healthcare settings. Nurses also should put the client at the center of care and incorporate the client as a part of the healthcare team. As such, nurses must collaborate closely with other members of the healthcare team and include all healthcare professionals caring for the client. Nurses should not cross professional boundaries with their clients by establishing friendships.

The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics: A duck waddle gait Shortened extremity Asymmetry of the gluteal folds Protruding abdomen The nurse then refers the toddler to the health care provider for potential diagnosis of which? o Developmental dysplasia of the hip (DDH) o Scoliosis o clubfoot (congenital talipes equinovarus) o Muscular dystrophy

o Developmental dysplasia of the hip (DDH) · Developmental dysplasia of the hip (DDH) exhibits signs of asymmetry of the gluteal folds, lordosis, swayback, protruding abdomen, shortened extremity, and a duck-like waddle. Congenital talipes equinovarus is clubfoot. Scoliosis is a curvature of the spine. Muscular dystrophy is a chronic degenerative muscular condition.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority? o Risk for infection related to the immune system dysfunction o Disturbed body image related to loss of fat in the face and arms o Deficient knowledge related to the effects of the disease o Risk for impaired liver function related to drug therapy effects

o Disturbed body image related to loss of fat in the face and arms · The client is experiencing lipoatrophy, which results in a localized loss of subcutaneous fat in the face (manifested as sinking of the cheeks, eyes, and temples), arms, legs, and buttocks. These changes as well as his statement about the side effects of the drug being worse than the disease indicate that he is concerned about how he appears to others. Therefore, the nursing diagnosis of disturbed body image would be the priority. Deficient knowledge, risk for infection, and risk for impaired liver function may be applicable; however, they are not concerns at this time.

The nurse is preparing a client for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. What information will the nurse include in the teaching? o The procedure takes less time than a cardiac catheterization. o During the procedure, the dysrhythmia will be reproduced under controlled conditions. o After the procedure, the dysrhythmia will not recur. o The procedure will occur in the operating room under general anesthesia.

o During the procedure, the dysrhythmia will be reproduced under controlled conditions. · During EP studies, the patient is awake and may experience symptoms related to the dysrhythmia. The client does not receive general anesthesia. The EP procedure time is not easy to determine. EP studies do not always include ablation of the dysrhythmia.

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the arrhythmia? o Pacemaker implantation o Defibrillation o Maze procedure o Elective cardioversion

o Elective cardioversion · Atrial fibrillation is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. Maze procedures are used for clients who are not candidates for cardiodiversion; these procedures use scar-forming techniques to eliminate rapid firing of ectopic pacemaker sites, thus restoring the normal conduction pathways in the atria. A Maze procedure might be considered for this client only after determining ineligibility for cardiodiversion. Pacemakers are implanted for bradycardia.

A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure? o Have two nurses stand on the side of the bed in the direction the client will be turned. o Enlist the assistance of two or three other nurses to perform the procedure. o Use a friction-reducing sheet that extends from below shoulder to above hips. o Have the client cross the arms on the chest and place a pillow over them.

o Enlist the assistance of two or three other nurses to perform the procedure. · When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the client. Two or three nurses can accomplish this safely by logrolling a client. Do not try to logroll the client without enough help. Do not twist the client's head, spine, shoulders, knees, or hips while logrolling. A friction-reducing sheet is used for other transfers, but not with the logrolling technique. The nurse would have a client cross the arms on the chest with other transfers, but not with the logrolling technique. A nurse should be on both sides of the bed of a client who is being logrolled, not just on the side that the client is being turned.

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? o Tell the charge nurse that the nurse is going to lunch. o Give the charge nurse information about what care should be given while the nurse is at lunch. o Verify that the charge nurse has assigned someone else to take care of the client. o Remind the charge nurse about the client's history and current medications.

o Give the charge nurse information about what care should be given while the nurse is at lunch. · Hand-off of care communication is an interactive communication allowing the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment, and services, as well as the client's current condition and any recent or anticipated changes. "Hand-off" communication does occur when a nurse is leaving the nursing unit, but the purpose is not to let the charge nurse know that the nurse is going to lunch or to have someone else assigned to care for the client. "Hand-off" communication focuses on current information, not the client's history.

Which group role is best reflected by the client who consistently validates members' contributions, tries to be the "mediator" between members, and interprets the group's procedures? o Group cohesion o Task o Individual o Group building and maintenance

o Group building and maintenance · Group building and maintenance roles are oriented toward overall group functioning. They alter or maintain the way of working to strengthen, regulate, and perpetuate the group. Individually oriented behavior, which often stems from anxiety, distracts from and temporarily stymies the group and its progress. Task roles promote growth and productivity. Group cohesion relates to bonding and solidarity, the feeling of "we" instead of "I."

Which group characteristic is lacking in the following statement: "Our group never talks about really emotional issues. I mean, no one ever cries." o Imparting of information o Countertransference o Group cohesiveness o Competition

o Group cohesiveness · Group cohesiveness is evident when members value each other's contributions and feel free to express opinions and emotions honestly. This statement reflects a group that is lacking cohesiveness. Countertransference occurs when the therapist responds negatively to the client's transference, further complicating communication. Competition refers to a process in group development where group members can develop rivalry but can positively affect the group outcome. In this case, competition is not reflected in the statement. Imparting information is the use of data in a planned, structured manner, such as didactic instruction given in a lecture format.

Which would be included as a responsibility of the scrub nurse? o Keeping all records and adjusting lights o Handing instruments to the surgeon and assistants o Obtaining and opening wrapped sterile equipment o Coordinating activities of other personnel

o Handing instruments to the surgeon and assistants · The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.

Which of the following is a duty of the registered nurse first assistant? Select all that apply. o Handling tissue o Suturing o Specimen management o Maintaining hemostasis o Providing exposure at the operative field

o Handling tissue o Suturing o Maintaining hemostasis o Providing exposure at the operative field · Handling tissue, suturing, maintaining hemostasis, and providing exposure at the operative field are responsibilities of the registered nurse first assistant. Specimen management is a duty of the circulating nurse.

A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent? o Give acetaminophen for the fever and pain, and have the child rest. o Have the child drink fluids that contain electrolytes. o Have the child go to the emergency room. o Have the child be seen by the primary care provider.

o Have the child be seen by the primary care provider. · Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

The nurse is caring for a neonate in the newborn nursery with clubfoot (congenital talipes equinovarus). If nonsurgical treatment is chosen, which nursing action is anticipated? o Passive range of motion of ankles o Holding feet/ankles in position for casting o Assisting in applying an ace wrap o Instruction on corrective shoes

o Holding feet/ankles in position for casting · The nurse is caring for a neonate with clubfoot (congenital talipes equinovarus). If nonsurgical treatment is chosen, the nurse action anticipated would be holding the feet and ankles in the position determined by the health care provider for casting. Serial casting over time will provide the appropriate correction. Ace wraps will not maintain the intended position. Corrective shoes alone do not change the position of the feet and ankle. A Dennis Browne splint includes shoes with the splint.

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most? o Home care o Acute care o Ambulatory care o Respite care

o Home care · Home health care services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their activities of daily living. Acute and ambulatory care are delivered on a short-term basis, and respite care's focus is on the caregiver.

A client has had a total knee replacement and will need to walk with crutches for six weeks. The client is being discharged home with a referral for home health care. What will the home care nurse need to assess during the initial assessment? o Assistance of neighbors o Costs of the visits o Previous health status o Home environment

o Home environment · The initial assessment includes evaluating the client, the home environment, the client's self-care abilities or the family's ability to provide care, and the client's need for additional resources. There is no assessment made of assistance on the part of neighbors, the previous health status, or the costs of the visit.

A psychiatric client's nurse case manager best explains to the family that case management will facilitate the client's transition back into the community by providing which services? o Identifying and meeting the client's health and human service needs o Contacting and maintaining relationships with the client's various service providers o Facilitating reimbursement and coverage by the client's private and public insurances o Prescribing nursing care directed toward managing the client's acute and chronic health problems

o Identifying and meeting the client's health and human service needs · Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual client's health and human service needs.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP? o Securing the client on a papoose board o Soothing the client during the procedure o Initiating intravenous therapy o Gathering equipment needed for intravenous therapy

o Initiating intravenous therapy · When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of that condition, and the potential for harm. Initiating intravenous therapy is reserved for the RN due to the potential for harm and the scope of the UAP. The UAP can assist the nurse by obtaining equipment, securing the client, and soothing the client.

A client comes to see the cardiologist for a routine follow-up visit. At the visit, the nurse reviews the client's electronic health record. The nurse is able to access a report from the client's last visit to the primary care provider last month and the report from an emergency department visit two weeks ago for reports of shortness of breath. The record also lists two changes in the client's medication based on the emergency department visit. The nurse's ability to access this information reflects which concept? o Security o Usability o Optimization o Interoperability

o Interoperability · Being able to access the client's information from multiple sources, that is share information across health care systems, reflects interoperability. Usability reflects a system's ease of use or intuitiveness. Optimization commonly includes strategies for improvement. Security reflects the privacy and confidentiality of the information.

The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist? o Organizational o Small-group o Intrapersonal o Interpersonal

o Interpersonal · The nurse and physical therapist are engaging in interpersonal communication, which occurs between two or more people with the goal to exchange messages. Intrapersonal communication, or self-talk, is the communication that happens within the individual. Small-group communication occurs when nurses interact with two or more individuals. Organizational communication occurs when individuals and groups within an organization communicate to achieve established goals.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction? o Consult with another experienced nurse for input. o Consult with the client's physician for appropriateness. o Remind the new nurse of the facility's policy and procedure. o Listen to the new nurse's suggestion and evaluate its usefulness.

o Listen to the new nurse's suggestion and evaluate its usefulness. · It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? o Maintain cerebral perfusion pressure from 50 to 70 mm Hg o Restrain the client, as indicated o Position the client in the supine position o Administer enemas, as needed

o Maintain cerebral perfusion pressure from 50 to 70 mm Hg · The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Which is the largest single source of reimbursement for home health care services? o Medicaid o Client's self-pay o Medicare o Private insurance

o Medicare · Medicare is the largest single source of reimbursement for home health care services. Other sources of reimbursement may include Medicaid, private insurance, self-pay, and other public funding.

A client is admitted to the hospital with an elevated temperature and flank pain. When reviewing the complete blood count (CBC), which level is the most important for the nurse to communicate to the health care provider? o Platelets 150,000/mL (150,000 x 109/L) o Hemoglobin 12.6 g/dL (126 g/L) o Monocytes 3% o Neutrophils 85%

o Neutrophils 85% · Neutrophils are very mobile and are the first cells to go to an area of tissue damage. The elevation in neutrophils indicates that the client has an acute infection (such as pyelonephritis) that is causing the temperature elevation and flank pain.

The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize? o Notify the RN who will then notify the health care provider. o Continue to monitor for another hour. o Administer an antipyretic. o Assist the client in ambulation.

o Notify the RN who will then notify the health care provider. · A temperature elevated above 100.4°F (38°C) is a sign of possible infection. The LPN should notify the RN. The RN will then notify the provider and receive further care orders for the client. Administering an antipyretic can only be done at the physician's order. Assisting in ambulation and continuing to monitor the client for another hour are not indicated interventions for this client.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention? o Elevate the head of the bed. o Observe vitals every two hours. o Notify the doctor immediately. o Administer epinephrine.

o Notify the doctor immediately. · The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first? o Call the Medical Response Team to her room. o Have another nurse come listen to the client's respirations and count the rate. o Notify the health care provider of the findings. o Ask the charge nurse to look in on the client before the end of the shift.

o Notify the health care provider of the findings. · If the nurse notes abnormal findings on her exam—such as depressed respiratory status like this client is presenting—the nurse will immediately notify a health care provider. Having a peer come in to confirm your findings is always fine but this does not preclude notification of the physician. Asking the charge nurse to look in on the client later indicates there is no urgency to the situation, which there is.

A nurse manager has asked the staff to create a plan to improve patient outcomes. In the past, the staff have not met deadlines. How can the nurse manager use transactional leadership style to ensure that the deadline is met? o Demand efficiency. o Give extensions as needed. o Ask politely. o Offer 2 days of paid vacation.

o Offer 2 days of paid vacation. · The transactional leadership style involves a task and reward system. Paid vacation is a reward for meeting the deadline. Asking politely, demanding efficiency, and giving extensions are not rewarding behaviors.

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. o Angiogenesis o Palliative care o Radiation o Respite care

o Palliative care · In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? o Pancreatic necrosis o Shock o Tetany o MODS

o Pancreatic necrosis · Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? o Gastroesophageal Reflux Disease (GERD) o Cirrhosis of the Liver o Peptic Ulcer o Chronic Constipation

o Peptic Ulcer · Any health problem that involves bleeding of the GI tract, such as peptic ulcer disease, may require fecal occult blood testing (FOBT). Constipation does not indicate a need for FOBT unless hardened stool is suspected of causing GI trauma. Similarly, GERD may require FOBT only if esophageal bleeding is suspected. Liver disease is not a common indication for FOBT.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? o Pigment o Patterned o Pixelated o Pearl

o Pigment · There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

Nursing students are reviewing information about the cognitive development of preschoolers. The students demonstrate understanding of the information when they identify that a 3-year-old is in what stage as identified by Piaget? o Preoperational thought o Primary circular reaction o Coordination of secondary schema o Tertiary circular reaction

o Primary circular reaction · A 3-year-old is in the preoperational stage according to Piaget. Primary circular reaction is seen in infants of 3 months. Coordination of secondary schema is seen in infants at age 10 months. Tertiary circular reaction is seen in toddlers between 12 and 15 months.

A 71-year-old client reports to the nurse that he often notices a pink tinge to his urine. Upon further questioning, he states that he experiences no pain when voiding and has not noticed any change in the frequency of his voiding. Which response by the nurse is best? o Promptly report this finding to the client's health care provider. o Instruct the client to avoid eating beets and berries to see if the issue resolves. o Perform intermittent catheterization to obtain a sterile urine specimen. o Encourage the client to record a "voiding log" for the next several days.

o Promptly report this finding to the client's health care provider. · Painless hematuria should be reported promptly because it is associated with bladder cancer. Frequency, urgency, and dysuria occasionally accompany the hematuria, but this is not always the case. It would be irresponsible to delay referral by suggesting diet changes or watchful waiting. Catheterization is unnecessary to obtain a urine specimen.

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team? o Provide direct independent care to the client. o Provide care under the supervision of an RN. o Observatory to assist the RN. o Assist the providers in the delivery room.

o Provide care under the supervision of an RN. · The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN.

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered healthcare worker (UHW)? Select all that apply. o Assess bowel sounds in all four quadrants. o Administer carboplatin 750 mg intravenously. o Provide report for the next shift. o Reinforce tape over an abdominal incision. o Document intake and output in the electronic medical record. o Ambulate in the hall for the first time after surgery.

o Provide report for the next shift. o Reinforce tape over an abdominal incision. o Document intake and output in the electronic medical record. · A complete and thorough assessment is needed by the registered nurse as the client is just returning from surgery. The RN may delegate to the LPN/VN or nursing assistant the responsibilities of documentation of intake and output and reinforcing tape over the abdominal incision. The LPN/VN may provide nursing report to the oncoming shift. The RN would administer carboplatin, a chemotherapeutic agent as this is out of the scope of practice of the LPN/VN. The RN would also complete any initial postoperative assessment such as bowel sounds and postoperative ambulation because the RN holds the responsibility of this nursing assignment. Review the management of care following a subtotal gastrectomy and delegation practices to answer this question.

A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take? o Receive the prescription over the phone and repeat it back to the HCP to verify accuracy. o Request the HCP text the prescription via mobile phone to reduce the risk for misinterpretation. o Ask the charge nurse to receive the telephone prescription from the HCP. o Reinforce that all client prescriptions must be entered directly by the HCP into the EHR.

o Receive the prescription over the phone and repeat it back to the HCP to verify accuracy. · The nurse should repeat every telephone prescription back to the HCP to ensure that the nurse correctly understands what was prescribed. Texting prescriptions over mobile phones is not an approved practice due to confidentiality concerns. Although it is ideal that the HCP enter the prescription directly into the EHR, when this access is not possible, the nurse can receive the telephone prescription to avoid delays to client treatment. Any registered nurse can receive telephone prescriptions so the nurse does not need to have the charge nurse perform the task.

The client is being discharged to the home setting following a stroke. Which activity would the occupational therapist assist the client with? o Improving the ability to swallow o Improving oral communication o Relearning how to cook safely o Gait training with a walker

o Relearning how to cook safely · The occupational therapist can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as cooking. The physical therapist provides direct care, such as muscle-strengthening exercises, gait training, and massage. The speech therapist assists with speech and language ability, as well as eating and swallowing.

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. o Planning education for a client with a colostomy o Taking routine vital signs o The determination of a nursing diagnosis for a client with breast cancer o Transferring a client to another floor o Giving a bed bath to a client o Administering medications to clients

o Taking routine vital signs o Transferring a client to another floor o Giving a bed bath to a client · The nurse should be familiar with guidelines for delegating nursing care. The nurse could delegate the following tasks to UAP: giving a bed bath to a client, taking routine vital signs, and transferring a client to another floor. The nurse could not delegate the administering of medications, planning client education for a client with a colostomy, or the determination of a nursing diagnosis.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? o The day the patient has the stroke o After the nurse has received the discharge orders o The day before the patient is discharged o After the patient has passed the acute phase of the stroke

o The day the patient has the stroke · Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? o The provider can input orders remotely into the EHR system for the nurse to retrieve. o The nurse can accept verbal orders to provide immediate care and record once the client is stable. o The nurse can implement care once written orders are received from the provider. o The client must be stabilized before the nurse can obtain any orders from the provider.

o The nurse can accept verbal orders to provide immediate care and record once the client is stable. · In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution? o The nurses ignore each other's request for the preceptor. o The nurses agree to allow the preceptor to decide which nurse to precept. o The nurses agree that one nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend. o The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

o The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end. · Compromise involves both parties willingly relinquishing something of equal value. The nurses' decision to share the preceptor, with one having the preceptor at the beginning of the orientation and the other at the end, demonstrates compromise. The nurses ignoring each other's request illustrates avoidance. Allowing the preceptor to decide which nurse to precept encourages competition. Competition involves a win-lose approach to conflict. The nurses agreeing that one nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend illustrates accommodation. Accommodation involves one party deciding to let the other party win in exchange for something else of value.

A 12-year-old girl needs a lumbar puncture to collect cerebrospinal fluid for a laboratory exam plus injection of medication into the central nervous system. She expresses great fear of the procedure because of anticipated pain and the inability to hold still. The nurse contacts the physician to make which suggestion? o Include the child's parents and a child life specialist in the procedure room. o Delay the procedure until the child can achieve better understanding and acceptance. o The use of conscious sedation for the lumbar puncture. o Administration of an oral antianxiety medication prior to the procedure.

o The use of conscious sedation for the lumbar puncture. · The nurse recognizes the child's fear and is acting as her advocate suggesting the use of conscious sedation. It will be the most effective way to relieve the child's anxiety, pain, and concern about cooperation. A medication given for anxiety prior to the procedure may ameliorate some stress and make lying still a bit easier but will not relieve pain. Support from parents and a child life specialist is helpful and can be part of the conscious sedation plan. Alone it would not be adequate to assist the child. Delaying the procedure to do additional teaching could be helpful in some situations but is not the best choice here.

The presence of mucus and pus in the stools suggests which condition? o Small-bowel disease o Ulcerative colitis o Disorders of the colon o Intestinal malabsorption

o Ulcerative colitis · The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.

A nurse is assisting with a bone marrow aspiration and biopsy for a 6-year-old child. Which would be most important? o Placing a folded blanket or pillow under the head to raise it. o Using aseptic technique for the procedure. o Asking the parents to leave the room for the procedure. o Positioning the child on the side.

o Using aseptic technique for the procedure. · The procedure is done using aseptic technique. The child is positioned based on the site of aspiration and a folded blanket or pillow is placed under the abdomen to elevate the hips. Parents should be allowed to stay in the room for emotional support.

A client with new onset atrial fibrillation (AF) is being admitted to the hospital for possible cardioversion. The initial vital signs include a heart rate of 160 and blood pressure of 90/60. The admission nurse anticipates the presence of a pulse deficit. To verify this finding which action would the nurse take? o Assess the radial pulse bilaterally for a full minute with the client in the lateral position. o Assess the apical pulse for a full minute with client in the supine position. o With another nurse, assess the apical and radial pulses simultaneously for one minute. o Assess both the carotid and radial pulses for a full minute.

o With another nurse, assess the apical and radial pulses simultaneously for one minute. · A pulse deficit, which results from changes in stroke volume due to varying time for diastolic filling, is noted as a difference in the rate of the apical and radial pulse. The most accurate means of assessing a pulse deficit is for two nurses to assess at the same time, one the apical rate and the other the radial. Then the radial rate is subtracted from the apical rate to determine the number of ventricular contractions that are not producing a palpable pulse. As the ventricular rate increases, the pulse deficit will also increase because there will be even less time for ventricular filling.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? o Use a critical pathway to document the physical assessment. o Place the narrative note chronologically after the respiratory therapist's note. o Write a narrative note in the designated nursing section. o Review the laboratory results under the physician section.

o Write a narrative note in the designated nursing section. · Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

The nurse is caring for several adolescent clients on the mental health unit. Which clients should the nurse suggest to join a group therapy session? Select all that apply. o adolescents with depressive disorder o adolescents with uncontrolled aggressive behavior o adolescents with a history of substance use disorder o adolescents who have experienced the death of a loved one o adolescents who have experienced rape

o adolescents with depressive disorder o adolescents with a history of substance use disorder o adolescents who have experienced the death of a loved one o adolescents who have experienced rape · In group therapy, feelings are expressed and participants gain hope, feel a part of something, and benefit from role modeling and talking with others who have been through the same experiences. The adolescent that is experiencing uncontrolled aggressive behavior would not be a good candidate for group therapy as · he may become more aggressive; this would also make the participants uneasy to attend the group.

The nurse is educating the family of a 2-year-old boy with bronchiolitis about the disorder and its treatment. The family parents speak only Chinese. Which action, involving an interpreter, can jeopardize the family's trust? o using a person who is not a professional interpreter o allowing too little appointment time for the translation o asking the interpreter questions not meant for the family o using an older sibling to communicate with the parents

o asking the interpreter questions not meant for the family · Asking questions or having private conversations with the interpreter may make the family uncomfortable and destroy the child/nurse relationship. Translation takes longer than a same-language appointment and must be considered so that the family is not rushed. Using a nonprofessional runs the risk that he or she won't be able to adequately translate medical terminology. Using an older sibling can upset the family relationships or cause legal problems.

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home? o reinforcing the importance of having renovations done before discharge to enable wheelchair access and accessibility to all needs for daily living o checking the cleanliness of the home, ensuring removal of clutter, and organizing all essentials on one level of the house o checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment o ordering a wheelchair, special utensils, and a raised toilet seat and rearranging the furniture in the home

o checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment · Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home.

The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called: o independent functioning. o collaborative functioning. o authoritative functioning. o assistive functioning.

o collaborative functioning. · Nurses manage collaborative problems using both nurse- and health care provider-prescribed interventions to reduce the risk of complications. In this situation, the nurse is not operating authoritatively or independently, but within the parameters established by the health care provider. The nurse is not merely acting in an assistive capacity, as the nurse is performing interventions in the absence of the health care provider.

Initiatives that strive to strengthen links between primary care and specialized mental health services refer to ... o collaborative mental health care. o inpatient psychiatric units. o partial hospitalization programs. o psychosocial rehabilitation programs.

o collaborative mental health care. · Collaborative mental health care refers to activities or initiatives that strive to strengthen links between primary care and specialized mental health services.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report? o results of laboratory tests o nursing treatment initiated o client's admission number o current client assessment

o current client assessment · The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? o biofeedback o patient controlled analgesia o percutaneous electrical nerve stimulation o cutaneous stimulation

o cutaneous stimulation · Acupressure, a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

A client is to receive medication by a continuous nerve block route. Prior to insertion of the catheter by the anesthesiologist, what information must the nurse document? Select all that apply. o duration of pain o nausea and/or vomiting o allergies o vital signs o weakness/numbness

o duration of pain o allergies o vital signs o weakness/numbness · Prior to the catheter insertion, the nurse must document location of pain and pain rating, level of consciousness (LOC), vital signs, and weakness or numbness, especially in the legs. The nurse should also ask if the client has allergies before medication administration.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? o bacterial vaginitis o genital herpes o gonorrhea o human papillomavirus (HPV)

o gonorrhea · Gonorrhea must be reported to the public health department. Bacterial vaginitis, genital herpes, and HPV aren't reportable diseases.

A scrub nurse in the operating room has which responsibility? o handing surgical instruments to the surgeon o assisting with gowning and gloving o applying surgical drapes o positioning the client

o handing surgical instruments to the surgeon · The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important? o increasing fluid intake to 3 L/day o encouraging the client to drink cranberry juice to acidify the urine o administering a sitz bath twice per day o using an indwelling urinary catheter to measure urine output accurately

o increasing fluid intake to 3 L/day · Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. Doing so helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain? o dry mucous membranes o pulmonary crackles o high urine output o hypertension

o pulmonary crackles · High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which practitioner? o occupational therapist o physical therapist o respiratory therapist o physician

o respiratory therapist · A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

What are important nursing responsibilities when a referral to other health team members has been made for a client? o recommending that each member read the history and nurse's notes to understand the client's progress o recommending that each health team member independently completes an assessment and then consult with each other o sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living o ensuring that the physician reports the level of functioning of the client

o sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living · Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer? o cooperative play o therapeutic play o play therapy o onlooker play

o therapeutic play · Therapeutic play is a play technique used to help the child better understand what will be happening to him or her in a specific situation. For instance, the child who will be having an IV started before surgery might be given the materials and encouraged to "start" an IV on a stuffed animal or doll. By observing the child, you can often note concerns, fears, and anxieties the child might express. Therapeutic play helps the child express feelings, fears, and concerns. The other types of play will not accomplish this goal.

A group of nursing students is discussing reasons why they would like to become home health nurses after licensure. The nursing instructor facilitating this discussion would offer additional information when which statement is made? Select all that apply. o "I would like to depend on my own knowledge when treating clients." o "I would like to spend more time talking with clients than doing skills." o "Home health nursing will work into my schedule better." o "I like the creativity that is possible when working in home health. " o "I don't think fast enough to work in a hospital."

o "I would like to spend more time talking with clients than doing skills." o "I don't think fast enough to work in a hospital." · Nurses who work in home health must have excellent care skills, including the ability to think and act quickly if necessary. Assessment skills are paramount, but the nurse must also possess excellent technical skills. The autonomy of depending on one's own knowledge and the creativity possible when working in home health are two reasons many nurses are drawn to the specialty. It is also often possible to arrange scheduling so that it better fits into the nurse's personal life.

A nurse has been asked to chair an action team tasked with prioritizing a list of possible new equipment purchases. Which statements, made by this nurse, will help the team be most effective? Select all that apply. o "I am willing to prioritize the list if someone else will write the rationale." o "When I got this assignment, they said something about deciding what equipment to purchase next year." o "Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." o "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." o "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be."

o "Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." o "Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." o "Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." · The most important component of team structure is to have a common goal. The goal of this group is to list potential equipment purchases with rationale. The second-most important component of team structure is to have clear roles and responsibilities. The direction by the nurse for the members to query nurses on each unit is an example of establishing clear roles and responsibilities. Teams also should hold themselves mutually accountable for achieving the goal, such as by having all the team members sign the recommendation. The work should be done by the team, not by just one or two members, as in the option about one nurse prioritizing the list and another writing rationale. Clarity and specificity are important in communicating the purpose of the team, both of which are lacking in the statement, "they said something about deciding what equipment to purchase next year."

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate? o "Each team member works independently of other team members." o "It requires that you have high-level critical care skills." o "You need a graduate degree to specialize in home health care." o "The client and family are in control of the setting, not the nurse."

o "The client and family are in control of the setting, not the nurse." · In home health care, the nurse is a "guest" in the client's home. Thus, the client and family retain the power and control that they normally relinquish to providers in other settings, such as an acute care facility. A generalist background and focus are useful, as well as broad assessment skills and a knowledge base to provide clients with appropriate education that will keep them as independent as possible. A graduate degree or high-level critical care skills are not necessary. Collaboration among team members is essential.

A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation? o "The client had an exploratory laparotomy 2 days ago and was progressing well. The vital signs were stable until this episode." o "The client began complaining of severe chest pain, rating it as a 10 on a scale of 1 to 10, after walking back from the bathroom." o "This event seemed to come out of the blue. The client denies any history of heart disease but does take a baby aspirin each night." o "The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes."

o "The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes." · SBAR provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of client safety. S stands for the situation (complaint, diagnosis, treatment plan, and client's wants and needs); B stands for background (vital signs, mental and code status, list of medications, and lab results); A stands for assessment (current provider's assessment of the situation); and R stands for recommendations (identification of pending lab results and what needs to be done over the next few hours, along with other recommendations for care).

A home care nurse has just completed a dressing change on her client. Which statement best describes the termination phase? o "Your wound is healing nicely. It is draining less and it is smaller by a half centimeter." o "Have you had any problems since our last visit? Is your wife doing well with your dressing changes?" o "You need to eat more protein to assist you with wound healing." o "On a scale of 0 to 10 with 0 being no pain and 10 being the worst, where would you rate your pain?"

o "Your wound is healing nicely. It is draining less and it is smaller by a half centimeter." · The summarization of the purpose of the visit is evident with the description of the accomplishments of the visit. Discussion of diet, pain, and evaluation of caregiver competency should be done before the termination of care.

A nurse is assisting the physician conducting a cystogram. The client has an intravenous (IV) infusion of D5W at 40 ml/hr. The physician inserts a urinary catheter into the bladder and instills a total of 350 ml of a contrast agent. The nurse empties 500 ml from the urinary catheter drainage bag at the conclusion of the procedure. How many milliliters does the nurse record as urine?

o 150 · The urinary drainage bag contains both the contrast agent and urine at the conclusion of the procedure. Total contents (500 ml) in the drainage bag consist of 350 ml of contrast agent and 150 ml of urine.

A 47-year-old male has decided he requires more exercise, needs to eat a heart healthy diet, and avoid alcohol. This patient has determined which of the following? o Aging is causing him to gain weight o He requires ways to deal with stress o He sees the benefits of weight reduction o A change in lifestyle influences health

o A change in lifestyle influences health · Individuals can influence their own health through behavior and lifestyle changes. There is no indication that he needs to lose weight or is experiencing excessive stress.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? o A client who has an abdominal incision o A client who has leg strength and can cooperate with the movement o A client with a thoracic incision o A client who is confined to bed rest

o A client who has leg strength and can cooperate with the movement · The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.

Which circumstance likely requires the most documentation and communication on the part of the nurse? o A client is being discharged home following a laparoscopic appendectomy 2 days earlier. o A client is being transferred from one medical unit of the hospital to another to accommodate a client on isolation precautions. o A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. o A client is returning to an assisted-living facility following a colonoscopy earlier that day.

o A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. · Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurse facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, and discharges home or to an existing facility may not require a formal report of any type.

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed? o Upper endoscopy o Abdominal CT scan o Thoracentesis o Abdominal paracentesis

o Abdominal paracentesis · Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but it can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.

The home health nurse is making a home visit for an older adult client recently discharged from the hospital after suffering a stroke. Which finding would most concern the nurse? o Area rugs are present in multiple areas throughout the house. o The client is living with an adult child's family. o The client's home has a basement with small staircase. o Medication bottles are on the counter without safety caps.

o Area rugs are present in multiple areas throughout the house. · An older adult client who recently suffered a stroke is at risk for injury from falls. Living with a family member would likely be an appropriate situation for the client. Medication bottles for an older adult should be kept where they are easy to reach. The medications likely do not have a child-proof safety cap. A house with a basement would not be concerning unless the client must enter the basement and the stairs are unsafe. Area rugs are a tripping hazard for a client who is a fall risk and should be removed.

Conflict has emerged on a nursing unit because new graduates have found that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? o Arrange for the newer nurses to organize the client assignment for a trial period. o Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. o Reassure the new graduates that the more experienced nurses are acting in the interests of both staff and clients. o Gather evidence over the next several weeks in order to determine if the practice is indeed happening.

o Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. · Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict. Gathering evidence does not directly address the conflict that currently exists and reassurance may be unwarranted and false. Allowing the new graduates to create the client assignment may perpetuate selfish practices and does not resolve animosity between the two camps.

During the initial visit to a client's home, the nurse should provide the client and family with what information? o Information on other clients in the area with similar health care needs o The nurse's phone number and home address o Dates and times of all future home care visits o Available community resources to meet their needs

o Available community resources to meet their needs · The community-based nurse is responsible for informing the client and family about the community resources available to meet their needs. During initial and subsequent home visits, the nurse helps the client and family identify these community services and encourages them to contact the appropriate agencies. When appropriate, nurses may make the initial contact. It is inappropriate to provide information on other clients; it is equally inappropriate for a nurse to provide the nurse's home address. It is not normally possible to provide details of every future visit at the initial visit.

A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? o Decrease the amount of minerals in the diet. o Include an increased amount of minerals in the diet. o Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test. o Avoid eating food at least 8 hours before the test.

o Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test. · The client is advised to refrain from taking sedative drugs or consuming drinks that contain caffeine at least 8 hours before the test because these may interfere with the EEG results. The client is not advised to increase or decrease the intake of minerals in the diet or to avoid eating food 8 hours before the test.

A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent? o Assisting in participation of the care-related decisions o Establishing rapport and showing willingness to listen o Documenting the procedure o Clearly defining the purpose and expectations of the admission

o Clearly defining the purpose and expectations of the admission · During the admission to the health care system, the nurse should clearly explain to the client the purpose and expectations of admission, such as what procedures will be covered. Explaining what procedures will be covered does not pertain to establishing rapport with the client, documenting a procedure, or helping the client participate in care-related decisions.

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges? o Clients with high home care needs are being discharged into the community. o Clients are in the hospital for a longer period of time. o Client use of ambulatory care has decreased. o Clients are locked into prenegotiated payment rates that have remained unchanged.

o Clients with high home care needs are being discharged into the community. · Clients are returning to the community with more health care needs, many of which are complex, thus increasing the need for home health care. Clients are not in the hospital for longer periods of time. Clients are not locked into payment rates that have remained unchanged. Client use of ambulatory care has not decreased but increased.

A nurse is assisting with the transfer of a client from the acute care facility to the rehabilitation facility for continued care. Which skill would be most important for the nurse to use to promote continuity of care? o Care planning o Documentation o Assessment o Communication

o Communication · Although assessment, documentation, and care-planning skills are important, continuity depends on excellent communication as clients move from one caregiver or health care site to another. Too often, breakdowns in communication among caregivers result in medical errors or deficient plans of care.

The client was scheduled to be discharged home with his daughter, who would help her father with daily needs. However, the daughter is being admitted to the hospital due to stroke. Which type of discharge should the client have due to this? o Nursing home discharge o Complex discharge o Basic discharge plan o Simple discharge

o Complex discharge · The discharge plan is more complex. This level of discharge plan involves interdisciplinary collaboration and coordination. The discharge planner takes responsibility for coordinating the activities necessary to transfer the client from one setting to another. Because the client had a caregiver prior to discharge and is now experiencing a change in functioning, the client and the client's daughter will need additional resources. A simple discharge is a discharge to one facility such as a home or apartment. A discharge plan has the necessary instructions the client is supposed to adhere to after discharge. These may include medications, weight bearing or lifting, and follow up appointment and care. Nursing home discharge is when a client is discharged to a nursing home. The discharge has a discharge plan that is sent to the nursing home.

The nurse is providing care for a patient in the hospital scheduled for discharge in the morning. The patient will require further services after discharge since recovery is not complete. What can the nurse do to ensure quality care delivery for this patient? o Inform the family members that someone will have to stay with the patient after discharge. o Inform the physician that the patient is not ready to go home yet. o Contact the case manager for coordination of care prior to discharge of the patient. o Call social services to check on the patient after discharge.

o Contact the case manager for coordination of care prior to discharge of the patient. · Coordination of care for patients from the time of hospital admission to discharge-and in many cases after discharge to the home care and community settings-is vitally important to ensure that they continue to achieve benchmarks of quality. Care coordination failure occurs when a patient is readmitted to the hospital shortly after discharge with the same condition for which he or she had been originally hospitalized. Health insurance plans are increasingly holding hospitals accountable for readmissions to the hospital within 30 days of hospital discharge, and many times the plans will not reimburse hospitals for costs associated with these readmissions. Therefore, patient care must be coordinated seamlessly from the inpatient hospital environment through the community care system. However, the current U.S. and Australian and New Zealand health care systems has been frequently criticized for its fragmented system of delivery. Two roles have evolved to provide improved care coordination: the case manager and the clinical nurse leader (CNL). The case manager role has evolved in Australia and New Zealand whereas the CNL role has not.

A client tells the nurse that he is experiencing floaters in the eye. What is the appropriate nursing intervention? o Prepare to administer eye drops o Contact the physician o Document presence of cataract o Document consensual response

o Contact the physician · The appropriate action by the nurse is to communicate the finding to the physician because floaters can be a precursor for retinal detachment. The primary symptom of retinal detachment consists of painless changes in vision. Commonly, flashing lights or sparks, followed by small floaters or spots in the field of vision, occur as the vitreous pulls away from the posterior pole of the eye. As detachment progresses, the person perceives a shadow or dark curtain progressing across the visual field.

Which action must the nurse perform on discharge of a client from an acute care facility? o Writing any orders for future home visits that may be necessary for the client o Writing a discharge order for the client o Coordinating future care for the client o Sending the client's records to the attending physician

o Coordinating future care for the client · Coordinating future care is a means for providing continuity of care so that the client and family needs are consistently met as the client moves from a care setting to home. The physician, not the nurse, writes the discharge order for the client, as well as any orders needed for future home visits. Sending the client's records to the attending physician is not necessary unless the physician asks for certain records to be sent to the physician's office.

The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan? o Establishment of priorities during the planning phase o Identification of problems and risks that require nursing management during the nursing diagnosis phase o Data gathering, identification of client strengths, and assurance of client safety during the assessment phase o Providing referrals and delegating and managing client care during the implementation phase

o Data gathering, identification of client strengths, and assurance of client safety during the assessment phase · Establishment of priorities, identification of problems and risks, and delegation and management of client care are all roles of the registered nurse during the nursing process. Data gathering, identification of client strengths, performance of assessments and assurance of client safety are role of the LPN when using the nursing process to develop the client plan of care.

The nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies? o Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? o Is the facility listed as a government-approved facility with no infractions? o Does the agency provide care to facilitate transition to a hospital? o How does the agency train employees for accountability and do they require a background check?

o Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? · The most important information a family should obtain before selecting a home health agency is determining whether the agency meets uniform standards for licensing, certification, and accreditation. Inquiring about infractions listed with government organizations is important but would not be a family's priority question. Home health agencies facilitate transition from hospital to home, not home to hospital. Home care agencies typically require background checks and conduct training of employees. While these requirements can and should be confirmed by the family, it is not the most important information to obtain.

A registered nurse is providing community-based health care for a client diagnosed with early onset dementia. Which strategy is best for the nurse to employ to facilitate the family participating in the client's care? o Reinforce the care plan to the family if it is determined the client is not properly cared for. o Encourage active participation of the client and family in health care decisions. o Provide referrals for health care professionals to perform the client's activities of daily living (ADLs). o Create a care plan based on the client's requests and inform the family of the client's wishes.

o Encourage active participation of the client and family in health care decisions. · In a community-based health care setting, the nurse should involve the client and the family in all health care decisions for the client. The nature of the relationship is that of a partnership based on respect, appreciation, and cooperation. Reinforcing to the family that the client is not well-cared for should be done, but it is more important to involve the client and family in the care. The client and family should be encouraged to provide ADLs as they are able. Client care decisions should be made in conjunction with the family, and the family should be encouraged to participate in those decisions. The client's plan of care should include input from the family.

Which is an appropriate nursing intervention in the care of the client with osteoarthritis? o Assess for gastrointestinal complications associated with COX-2 inhibitors o Provide an analgesic after exercise o Avoid the use of topical analgesics o Encourage weight loss and an increase in aerobic activity

o Encourage weight loss and an increase in aerobic activity · Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methyl salicylate may be used for pain management.

Which is the primary goal of continuity of care? o Minimizing nurses' legal liability during client transitions between health care institutions o Increasing clients' knowledge base and improving their health maintenance behaviors o Ensuring a smooth and safe transition between different health care settings o Controlling costs and maximizing client outcomes after discharge from the hospital

o Ensuring a smooth and safe transition between different health care settings · Continuity of care exists to ensure smooth and safe transitions for clients when moving from one health care setting to another. This requires that all providers involved in the client's care effectively communicate the client's health information among themselves so that the client may maximize recovery and health. The primary goal of continuity of care is not to build the client's knowledge base or improve health maintenance behaviors, minimize the nurse's legal liability, or control health care costs.

A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take? o Have the home health aide increase visits for bathing the client. o Have the occupational therapist assess for the client's need for adaptive devices. o Have the social worker visit the client to discuss care options. o Have the physical therapist help the client with rehabilitation.

o Have the social worker visit the client to discuss care options. · Services to manage health care needs in the home can involve a team of interdisciplinary professionals, including social workers. The social worker is able to broadly identify resources to meet the client's needs. As no specific needs are indicated in this case, such as the need for rehabilitation, bathing, or adaptive devices, it would be more appropriate for the nurse to refer the client to the social worker than to a physical therapist, home health aide, or occupational therapist.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? o Full-liquid o High-protein o 1,800-calorie ADA o Low-fat

o High-protein · Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

The nurse is planning discharge of the client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires home medical services. Which item would be provided by home medical services? o Pain management o Intravenous therapy o High-rise toilet seat o Homemaking

o High-rise toilet seat · Home medical services provide durable medical equipment, such as walkers, canes, crutches, wheelchairs, high-rise toilet seats, commodes, beds, and oxygen. Custodial services include homemaking and housekeeping services, as well as companionship and live-in services. Hospice services provide pain management, physician services, spiritual support, respite care, and bereavement counseling. High-technology pharmacology services provide intravenous therapy, home uterine monitoring, ventilator management, and chemotherapy.

Which points should be included in the medication teaching plan for a client taking adalimumab? o The client should continue taking the medication if fever occurs. o It is important to monitor for injection site reactions. o The medication is given at room temperature. o The medication is administered intramuscularly.

o It is important to monitor for injection site reactions. · It is important to monitor for injection site reactions when taking adalimumab. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs.

Which are components of the nursing case management process? Select all that apply. o Prescribing medications o Monitoring medical progress o Filing and completing paperwork o Making referrals o Coordinating o Driving a client to appointments

o Monitoring medical progress o Filing and completing paperwork o Making referrals o Coordinating · Coordinating, making referrals, monitoring medical progress, and filing and completing paperwork are just a few of the tasks that the nurse case manager performs on a regular basis. Prescribing medications and driving a client to appointments are beyond the scope of practice of a nurse.

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? o Nurse case manager o Nurse manager o Insurance company o Physician

o Nurse case manager · The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

Which type of home healthcare agency is a local health department? o Official or public agency o Institution-based agency o Private, proprietary agency o Private not-for-profit agency

o Official or public agency · Health departments are public agencies supported through tax dollars and benefit the community in which they are located. Private not-for-profit agencies are supported by donations, endowments, charities, and insurance reimbursement. Private, proprietary agencies are usually for-profit organizations governed by individual owners or national corporations. Institution-based agencies operate under a parent organization, such as a hospital.

A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include? o Accountability that is primarily attributed to the patient o Nurses and physicians playing major roles in clinical decisions o A discussion of a centralized organizational structure o Participation in decision making that is shared by all involved

o Participation in decision making that is shared by all involved · The collaborative practice model involves all care providers, including nurses, physicians, and ancillary health personnel as well as the patient functioning within a decentralized organizational structure to collaboratively make clinical decisions. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment that strives to meet the complex health care needs of the public.

Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits? o Apply more conservative interventions than those used in a hospital setting. o Integrate the client's learning needs and goals into plans of care. o Perform thorough, accurate, and timely documentation. o Have the client sign a waiver prior to the entry phase of a visit.

o Perform thorough, accurate, and timely documentation. · The need for thorough documentation is especially high in home health care settings, both to ensure continuity of care and to provide a legally acceptable record of what occurred during nurse-client interactions. The nurse should not implement more conservative interventions solely to minimize liability. A waiver of rights is not a component of home health care. The client's learning needs and goals should indeed be integrated into plans of care, but this action does not protect against lawsuits.

The nurse is notified that a client is being admitted to the unit in a wheelchair from emergency for observation. The nurse delegates the preparation of the room to the unlicensed assistive personnel (UAP). What instruction(s) does the nurse provide? Select all that apply. o Place an admission pack in the room. o Bring all equipment for vital signs to the client's room. o Bring the client's bed to the highest position for easy transfer. o Place a "No Visitors" sign on the door until admission is complete. o Prepare an open bed in the low position.

o Place an admission pack in the room. o Bring all equipment for vital signs to the client's room. o Prepare an open bed in the low position. · Preparing the room for admission may be delegated by the nurse. The bed should be placed for easiest access: low if the client is ambulatory/can stand, and high if being transferred from a stretcher. Room preparation includes assembling all needed equipment and client supplies. It remains the nurse's responsibility to determine that all preparations are completed.

When doing discharge planning for an older adult client who had a stroke, what is the nursing priority? o Plan reachable goals with the client and family. o Involve the family in discussing when the client will go home. o Realize that goals may not be met after discharge. o Help the client after discharge to establish goals.

o Plan reachable goals with the client and family. · Goals are best met when mutually set by both the client and the nurse, with input from the family. If the client is involved in setting the goals, it is more likely that the expected outcomes of the plan will be met. The goals should be reachable by the client. Although the family should be included in discharge planning, they should have no say in when the client goes home, as this is determined by the client's physician. The goals should be planned before the client is discharged, not afterward. Of course goals may not be met after discharge, but realizing this should not be the nurse's priority; planning reachable goals should be the priority.

The home care nurse is providing care and education to a client who is pregnant for the first time. The client states, "I have no money or food. I don't know what I should do. I want to provide for my unborn child." The nurse refers the woman to the WIC program and a local food bank. This is an example of what aspect of community-based nursing? o Planning o Assessment o Evaluation o Restoration

o Planning · Planning and intervention focus on using individual, family, and community resources to assist in restoring a client's health to maximum possible functioning, while continuing to monitor for possible side effects or complications to treatment. Assessment involves determining the client's care needs. Restoration involves helping a client regain a former level of functioning after an injury or other debilitating health event. Evaluation involves determining the effectiveness of a care plan after it has been implemented.

When initiating home health care services, during which phase is it appropriate for the home health nurse to implement the initial client assessment? o Termination phase o Initiation phase o Referral phase o Pre-entry phase

o Pre-entry phase · Initial assessment is conducted by the nurse during the pre-entry and entry phases of the home visit. The referral phase involves the physician or discharge planner of a hospital contacting the home health care agency with the indications for the referral. The initiation phase consists of clarifying the source of referral and the purpose of the visit, as well as the initial contact with the family. Determining the need for further visits occurs during the termination phase.

Which type of agencies provide documented home health care services? Select all that apply. o Private businesses o Unofficial neighborhood groups o Private not-for-profit agencies o Off-duty neighborhood nurses o Hospital-based agencies

o Private businesses o Private not-for-profit agencies o Hospital-based agencies · Home health care services are provided by official, publicly funded agencies; nonprofit agencies; private businesses; private not-for-profit agencies; and hospital-based agencies. Unofficial neighborhood groups and off-duty neighborhood nurses are not agencies that provide documented home health services.

What is the priority nursing responsibility when transferring a client from one unit in the hospital to another? o Transport the completed client chart to the receiving unit. o Provide a verbal report of the client's status to the admitting nurse. o Help the client become familiar with the new unit. o Bring all of the client's belongings to the new unit.

o Provide a verbal report of the client's status to the admitting nurse. · Although the nurse may transport belongings and the chart, the priority responsibility for the nurse is the verbal report/communication with the nurse on the new unit. It is not the task of the nurse who brings the client to the new unit to orient the client.

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client? o Discussing the move with both client and the family. o Notifying all departments of the room change. o Asking family members to meet with the social worker at the receiving facility prior to the client's arrival. o Providing accurate and complete communication to the new facility.

o Providing accurate and complete communication to the new facility. · To ensure continuity of care for the client, the nurse should send a detailed assessment and care plan from the hospital to the extended care facility. Frequently, the nurse at the hospital provides a verbal report to the nurse at the new facility using the approved handoff technique. Other departments at the hospital should be notified of the client's discharge, but this does not affect the client's continuity of care. Discussing the move with the client and family is important, but this does not ensure continuity of care. The family members are asked to meet with the social worker but, again, this does not ensure continuity of care.

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning? o Providing client education o Making home health care referrals o Developing goals with the client o Assessing the client's needs and identifying problems

o Providing client education · The nurse is teaching the client important information about self-care at home prior to the client's discharge. The initial step in discharge planning is collecting and organizing data about the client, as this provides information on the client's health care needs. Home referrals may be made after the education process, based on orders provided by the physician. Developing goals may occur after the education process, as the goals need to be realistic.

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client? o Refer the client to a social worker to determine eligibility for assistance. o Enlist the services of the client's family for some components of care, such as dressing changes and physical therapy. o Refer the client to a local religious organization or non-profit agency for support. o Discuss the client situation with the provider for possible therapies that are more cost-conscious.

o Refer the client to a local religious organization or non-profit agency for support. · Social workers assist in finding and connecting the client with community resources or financial resources and provide counseling and support. A social worker is better equipped to find community resources or financial resources than a health care provider. Discussing alternative therapies with the provider may be beneficial, but typically this does not apply to some medical supplies that the client needs. Likewise, having the client's family participate in dressing changes is helpful, but will not particularly offset certain medical supplies that may be needed. Local non-profit organizations and religious organizations may be able to offer some assistance, but a social worker would be the best person to find resources and make referrals.

Which facility is an example of a tertiary health care setting? o Outpatient surgery center o Medical division in the hospital o Ambulatory care clinic o Rehabilitation facility

o Rehabilitation facility · Tertiary care settings include rehabilitation and long-term care facilities.

A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately? o Smell of natural gas o Infestation with roaches o Diminished food sources o Unclean environment

o Smell of natural gas · A comprehensive home assessment includes safety, sanitation, mobility, temperature, and personal space. All of the listed deficiencies are of a concern. The immediate concern for the nurse's and client's safety is the threat of fire or explosion due to the smell of natural gas.

Which qualities are essential for a community-based nurse? Select all that apply. o Strong knowledge foundation o Keen physical assessment skills o Competence in assisting with minor surgical procedures o Ability to delegate client care tasks to unlicensed assistive personnel o Effective communication skills

o Strong knowledge foundation o Keen physical assessment skills o Effective communication skills · Community-based nurses must possess several key qualities: they must be knowledgeable and skilled in their practice (including strong and effective communication and physical assessment skills), able to make decisions independently, and willing to remain accountable. They are less likely need skills in delegating client care or assisting with minor surgical procedures, as the nurse will typically work alone and as surgical procedures are not performed in the home care setting.

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management? o Psychosocial needs o Medication management o Support system o Transportation

o Support system · A client who has had bowel surgery, particularly an older client, would require much assistance in performing activities of daily living while recovering. Because this client lives alone and has no family available, the client may not be able to stay at home and may need to be placed in a facility to provide adequate support. A strong support system could meet the client's needs for medication management, transportation, and psychosocial support. A lack of a support system would likely mean that none of these other needs would be met. Thus, the client's support system is the most important factor related to home care management.

Why is it important for the home health nurse to inform the health care agency of the nurse's daily itinerary? o Allows easy accessibility of the nurse for changes in assignments o Supports suggested safety precautions for the nurse when making a home care visit o Allows the client to cancel appointments with minimal inconvenience o Allows the agency to keep track for payment of the nurse

o Supports suggested safety precautions for the nurse when making a home care visit · Whenever a nurse makes a home visit, the agency should know the nurse's itinerary for the safety of the nurse. Providing the agency with a copy of the daily schedule is not for the purpose of correctly paying the nurse; nor for the ease of the nurse in changing assignments or for the client's ease in canceling appointments.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response? o Have another nurse witness and record the order into the medication administration record (MAR). o Tactfully request the provider to input the order into the computerized provider order system. o Refuse to implement the order and notify the nurse manager. o Input the order into the computerized provider order system.

o Tactfully request the provider to input the order into the computerized provider order system. · Providers are to enter their own orders when they are physically present. It is appropriate for the nurse to tactfully request that the provider do so. The nurse should not input the order, nor refuse to implement it.

A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services? o Changes to the structure of Medicare and Medicaid o The increase in the incidence and prevalence of infectious diseases o The need for decreased financial expenditures o The change to shorter hospital stays

o The change to shorter hospital stays · Decreased hospital stays have led to an increase in community-based health care services, including home health services. This phenomenon has not been directly linked to structural changes in Medicare or Medicaid, financial considerations, or changes in disease patterns.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role? o The staff nurse is learning about all the hospital policies from the charge nurse. o The charge nurse is providing support for the staff nurse in new responsibilities. o The staff nurse is orienting to the unit as a newly hired nurse. o The charge nurse is being paid to supervise the staff nurse.

o The charge nurse is providing support for the staff nurse in new responsibilities. · A mentor is not a paid position, but, instead, is a person who provides support and encouragement to a less experienced nurse who is learning new responsibilities for a current role or an expanded one. Preceptorship typically is a paid position, and is provided for a new or experienced nurse who is training for a new position on a unit. The preceptor would teach the new nurse about hospital policies and procedures, as well as supervise the nurse in daily assignments.

A client is receiving home health services after having a stroke and being hospitalized. After a thorough assessment of the home environment and the client, what would indicate to the nurse that there is an impairment in the client's home management? o The client's caregiver is absent whenever the nurse visits and the client is alone. o The client reports having slipped in the restroom the first night in the hospital. o The client refuses to allow the caregiver to help the client sit up in bed. o The home care nurse has to reschedule an appointment with the client.

o The client's caregiver is absent whenever the nurse visits and the client is alone. · The nurse determines that there is an impairment in home management when the caregiver is not present to provide care to the client as well as answer questions regarding the care of the client. Education should be able to be provided to the client and caregiver. The nurse having to reschedule an appointment may occur for any number of reasons, but the client should have support in the home even if the nurse is unable to be there. Refusal of care does not indicate home management impairment. Slipping in the hospital environment has no bearing on home management.

The nurse is preparing to begin the discharge planning process with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process? o The client's potential for recurrence o The nurse's knowledge base and experience level o The NANDA diagnoses relevant to the client's condition o The client's identified needs and goals

o The client's identified needs and goals · The central focus of client teaching and the larger discharge planning process should be the identified health care needs of the client and the goals that the client identifies or acknowledges. The nurse's skills and knowledge, the client's potential for recurrence, and the relevant NANDA nursing diagnoses are all elements that may inform the discharge planning process, but they are superseded by the client's goals and expressed needs.

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting? o The discharge home of clients who are more critically ill o The chronic nursing shortage o The focus on treatment of disease o The preference of nurses to work during the day instead of evening or night shifts

o The discharge home of clients who are more critically ill · With shorter hospital stays and increased use of outpatient health care services, more clients who are critically ill require nursing care in the home and community setting. The other answers are incorrect because they are not the basis for the growth in nursing care delivered in the home setting. The chronic nursing shortage and the focus on the treatment of disease do not affect the growth in home health care, because both of these factors have no more or less of an effect on home health care than they do care provided in an acute care facility. Nurses, as a whole, do not necessarily prefer to work during the day rather than at night; some prefer to work in the day and some prefer to work at night. In any case, nurses work both day and night shifts in home health care just as in an acute care facility.

cognitive skill would this nurse need to ensure continuity of care? o The commitment to securing the best setting for care to be provided for clients and the best coordination of resources to support the level of care needed o The ability to establish trusting professional relationships with clients, family caregivers, and health care professionals in different practice settings o The ability to provide technical nursing assistance to meet the needs of clients and their families o The knowledge of how to communicate client priorities and the related plan of care as a client is transferred between different settings

o The knowledge of how to communicate client priorities and the related plan of care as a client is transferred between different settings · Continuity depends on excellent communication as clients move from one caregiver or health care site to another. Breakdowns in communication often result in medical errors due to lack of continuity of care. Technical skills are necessary to provide one aspect of good client care but do not always require a great deal of cognitive skills, nor do they ensure continuity of care. Trusting relationships help in developing good rapport for a working relationship but are not associated with cognitive skills. Securing the best setting and resources provides coordination of care but is not a cognitive skill.

It is important for home health care nurses to remember which point? o The nurse is the primary caregiver. o Rehabilitation is the major client goal. o The nurse is the guest in the client's home. o The nurse should act as a counselor and advisor.

o The nurse is the guest in the client's home. · An essential difference in home care versus acute care is that the home care nurse is a guest in the client's home. Family or other support persons are the primary caregivers, rehabilitation may not be the goal, and the nurse does not typically act as a counselor or advisor.

A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process? o The nurse determines who should be involved in the handoff communication. o The nurse prepares the new room for the client. o The nurse uses the SBAR technique during the handoff. o The nurse asks the other health care professionals if they have any questions.

o The nurse prepares the new room for the client. · The nurse prepares the new room for a client prior to admission, not during the discharge process. The client handoff refers to transferring responsibility for a client from one caregiver to another with the goal of providing timely, accurate information about a client's plan of care, treatment, current condition and anticipated changes. The nurse determines who she needs to communicate with during the discharge and asks those health care professionals if they have any questions in order to provide continuity of care. SBAR (Situation-Background-Assessment-Recommendation) is an outline that many facilities follow to ensure that proper communication occurs during the handoff procedure.

A nurse is using the ISBARQ (introduction, situation, background, assessment, recommendation, and question and answer) framework for handoff communication. Which examples accurately represent this process? Select all that apply. o The nurse makes arrangements for future home health care visits for the client who is being discharged from the hospital. o The nurse introduces the client to the health care professionals who will be involved in the new facility. o The nurse reports the current provider's assessment of the client and need for further services. o The nurse explains the client's chief complaint, diagnosis, treatment plan, and wants/needs. o The individuals involved in the process identify themselves, their roles, and their jobs. o The nurse reports the client's vital signs, mental and code status, medications, and lab results.

o The nurse reports the current provider's assessment of the client and need for further services. o The nurse explains the client's chief complaint, diagnosis, treatment plan, and wants/needs. o The individuals involved in the process identify themselves, their roles, and their jobs. o The nurse reports the client's vital signs, mental and code status, medications, and lab results. · ISBARQ provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated and how communication will occur between members of the health care team. Introduction refers to those involved in the client handoff identifying themselves, their roles, and their jobs. Background includes the client's vital signs, mental and code status, medications, and lab results. Situation includes the client's chief complaint, diagnosis, treatment plan, and client wants and needs. Assessment includes the nurse reporting the current provider's assessment of the client and need for further services. Introduction of the client and making arrangements for home care are not included in handoff communication.

Which member of the health care team is most often responsible for providing the order that will begin a client's course of home health care? o The case manager o The physician o The hospital discharge planner o The registered nurse

o The physician · Although referrals for home health care may originate from a variety of professions, the order that is required for care to proceed is provided by the physician or, in some cases, a nurse practitioner. Case managers, registered nurses, and hospital discharge planners do not have the authority to issues such an order.

A client is diagnosed with mild dementia while in the hospital. In preparing for discharge, what should the nurse discuss with the family? o The lack of free resources for care o The need for transfer to a long-term care facility o The possible need for home care o Legal responsibility for the future

o The possible need for home care · The needs of the client should be considered when making discharge plans. Common risk factors associated with the need for home care include limited social, mental, or physical functioning. There is no legal issue that is pertinent to the client's discharge at this time. The client's need for long-term care would be determined by the physician; though the client currently demonstrates mild dementia, there is no indication that client requires long-term care at this time. There is no indication that the client lacks resources for care, free or otherwise.

When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided? o The home health care aide o The registered nurse o The chaplain or minister o The social worker

o The registered nurse · Regardless of the number of providers for home health care, the responsibility for care coordination remains with the registered nurse, not with the social worker, chaplain or minister, or home health care aide.

The nurse is discharging a client who is living with diabetes. Which education topic(s) will the nurse discuss with the client and caregiver? Select all that apply. o The timing and appropriate method of administration of all medications o Information about home care and physical therapy with appropriate phone numbers o How to find a dietitian from home for meal plans o A review of the appointment schedule for follow-up care o How to perform dressing changes

o The timing and appropriate method of administration of all medications o Information about home care and physical therapy with appropriate phone numbers o A review of the appointment schedule for follow-up care o How to perform dressing changes · Client education prior to discharge is essential and should include written information to support the lesson. This may include information about appointments, medications, home care, specific conditions, and so on. The nurse must evaluate that the caregiver is adequately prepared to do dressing changes or provide other care safely. If the client needs help from the dietitian, the nurse should make the referral prior to discharge.

A nurse is caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form? o To ensure that the client knows that the client must still pay the bill o To let the cafeteria staff know a meal will no longer be required o To have relevant information all in one place in case the client is readmitted o To release the physician and the institution from any legal responsibility

o To release the physician and the institution from any legal responsibility · A client who decides to leave the hospital AMA must sign a form. This form releases the physician and the health care institution from any legal responsibility for declines in the client's health resulting from leaving the hospital AMA. The client should be informed of any possible risks before signing the form. The client's signature must be witnessed, and the form becomes part of the client's record. The form does not address the client's financial responsibility for care received nor does it alert the cafeteria that a meal is no longer needed for the client. Relevant information related to the client is in the medical record, not in the AMA form.

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize? o Work effectively in interdisciplinary teams o Navigate the electronic medical records system o Correctly utilize and troubleshoot high-tech equipment o Do things the way they have always been done

o Work effectively in interdisciplinary teams · The RN working with administrators to transform care will need to be able to work effectively as part of an interdisciplinary team. The nurse will need to work as a team member with members of the administration, as well as representatives from other health disciplines involved in the project. The ability to use and troubleshoot equipment and to navigate the electronic medical records are important to the nurse, but will not necessarily help when working with administration to transform care. Doing things the way they have always been done is a barrier to transformation of care.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? o Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. o Review and revise the way client education is conducted in the surgeons' office. o Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. o Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints.

o Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. · Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

A nurse is caring for a small child with leukemia who will be hospitalized frequently for chemotherapy. What type of referral can the nurse make that will help the child and family through this time? o child psychologist o play therapist o child life specialist o occupational therapist

o child life specialist · A child life specialist (CLS) is a specially trained individual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful. The CLS is a member of the multidisciplinary team and works in conjunction with health care providers and parents to foster an atmosphere that promotes the child's well being. The CLS provides therapeutic play, nonmedical preparation for surgeries and procedures, support for siblings, advocacy for the child and family, and grief/bereavement support. An occupational therapist would be needed if there were injuries to the upper extremities or hands. A child psychologist would only be warranted if the child was exhibiting psychological distress.

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to: o allow a religious leader in the client's life to visit. o increase the client's activity to assist in coping. o be certain that the client's educational needs are being met. o communicate these feelings to family and friends.

o communicate these feelings to family and friends. · The home health care nurse can assist in coordinating care needs and encouraging family, teachers, schoolmates, and friends to understand the client's struggles and help support the client's needs. Encouraging the client to allow a religious leader to visit may or may not be appropriate, depending on the client's beliefs. Ensuring that the client's educational needs are being met does not address the client's emotional and spiritual needs. Because the client has fractures and multiple trauma injuries, increasing activity is not likely to be an option and, in any case, would not directly address the client's emotional and spiritual concerns.

Continuity of care is an important concept for quality nursing practice. The responsible nurse understands the best description of the process of continuity of care is to: o manage the individual care needs of the client throughout the hospital stay. o coordinate uninterrupted care and facilitate transfer between units and levels of care. o teach the client self-care regarding medications and plan of care. o assist the client to focus on health goals and reach outcomes.

o coordinate uninterrupted care and facilitate transfer between units and levels of care. · The most comprehensive description of continuity of care is appropriate, uninterrupted care that facilitates transfer of the client between settings and levels of care. The others address specific needs/goals of the client, but do not describe coordination of care that provides for consistency and continuity.

A home health care nurse develops a client's individualized plan of care during the: o entry phase. o pre-entry phase. o referral process. o discharge planning.

o entry phase. · Nurses provide home health care interventions during the entry phase, using an individualized plan of care for each client based initially on identifying individualized health care needs. In the entry phase, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes (along with the patient and family), plans and implements prescribed care, and provides teaching. During the pre-entry phase, which includes the referral process, the provider or discharge planner of a hospital contacts the home care facility and provides a brief medical history, along with indications for home health services, and then the referral nurse at the home care facility collects as much information as possible about the patient's diagnoses, surgical experience, socioeconomic status, and treatments ordered. Discharge planning occurs during the pre-entry phase and would be too soon for creating a client's individualized plan of home health care, as the home health nurse still needs to meet and assess the client and family first.

Continuity of care for a particular client is most important to prevent: o rising health care costs. o multiple providers. o infection. o fragmentation of services.

o fragmentation of services. · Continuity of care is the provision of health care services without disruption, regardless of movement between settings. It is most important in preventing fragmentation of health care services. It does not prevent a client from needing the services of multiple providers, although it can ensure better communication and coordination among these providers, resulting in improved outcomes for the client. Continuity of care would not directly prevent infection, but in preventing fragmentation of care, it could indirectly help prevent infection. Ensuring continuity of care for a single client would not help prevent rising health care costs, in general, although it could help lower some costs for the individual client by reducing redundancy.

Which therapeutic factor refers to the group members' relationships to the therapist and other group members? o group cohesion o altruism o catharsis o universality

o group cohesion · Group cohesiveness refers to the group members' relationships to the therapist and other group members. Catharsis is the open expression of affect to purge or "cleanse" oneself. Altruism is learning to give to others. Universality refers to finding out that others have similar problems.

Community-based health care is best defined as: o health care directed to members of a community who are currently healthy. o health care that is not provided to specific individuals. o health care in a non-hospital setting. o health care developed in partnership with communities.

o health care developed in partnership with communities. · Community-based health care is developed within the context of a community. It is ultimately delivered to individuals and is not limited to healthy people. There are many examples of care outside of hospitals that are not considered to be community care.

When educating clients in the community on health promotion and prevention of disease, it is important to stress: o the ideal location for education is in a health care institution. o strenuous exercise is necessary for health. o health education can benefit individuals and groups. o health promotion may not be possible for many of the older members of a community.

o health education can benefit individuals and groups. · An axiom of health promotion and disease prevention is the fact that health education is highly beneficial. These benefits are not the same for everyone, but everyone can benefit from some sort of health promotion, including older clients. Strenuous exercise is not appropriate for everyone. Education does not always need to happen in a formal healthcare setting.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: o increased number of overall pregnancies. o longer length of labor. o poor quality of prenatal care. o increasing birth weight.

o increasing birth weight. · Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.

A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? o registered dietitian o nursing assistant o occupational therapist o physical therapist

o occupational therapist · An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn't trained in modifying utensils.

An adolescent is admitted to the adolescent unit with pain caused by sickle cell crisis. Who should be consulted first about this adolescent's care? o nutritionist o physical therapist o case manager o pediatric pain specialist

o pediatric pain specialist · Children and adolescents hospitalized with sickle cell crisis are commonly in excruciating pain. Therefore, the pediatric pain specialist should be consulted first to help relieve the adolescent's pain. The adolescent also requires hydration with I.V. fluids, but consulting a nutritionist isn't important at this time. Bed rest is commonly ordered to minimize energy expenditure and oxygen demand; therefore, consulting a physical therapist isn't necessary at this time. It isn't necessary to consult the case manager first; pain relief is most important at this time.

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to: o prepare the client for home care. o provide client education. o evaluate the effectiveness of the hospitalization. o determine hospital-based services needed by the client.

o prepare the client for home care. · Given that this client is being discharged from the acute care facility following a stroke, it is most likely that the nurse is calling a meeting of the entire health care team and the client and family to prepare the client for home care. Simply providing client education or evaluating the effectiveness of hospitalization could be done by the nurse alone and would not warrant calling a meeting with the entire health care team. As the client is being discharged, there is no reason to discuss hospital-based resources that the client might need.

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to: o discuss the return to familiar surroundings with the client. o communicate to the next of kin so they are aware of the transfer. o provide for the coordination and continuity of care by the health care providers. o ensure that the current health state of the client is maintained.

o provide for the coordination and continuity of care by the health care providers. · The primary responsibility of the nurse is to ensure continuity of care by communicating the client's status and needs. The nurse cannot ensure the health status of the individual. The nurse may notify the next of kin of the transfer and also discuss this with the client, but these are not the primary nursing responsibilities.

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to: o discuss the return to familiar surroundings with the client. o ensure that the current health state of the client is maintained. o provide for the coordination and continuity of care by the health care providers. o communicate to the next of kin so they are aware of the transfer.

o provide for the coordination and continuity of care by the health care providers. · The primary responsibility of the nurse is to ensure continuity of care by communicating the client's status and needs. The nurse cannot ensure the health status of the individual. The nurse may notify the next of kin of the transfer and also discuss this with the client, but these are not the primary nursing responsibilities.

Public health nursing is the branch of nursing that: o provides primary care to individuals. o assesses individuals for community care. o administers care for a defined geographic community. o provides health care for the community.

o provides health care for the community. · Public health nursing focuses on the whole population and the health of the community at large, not just on assessing or providing care to individuals. Community-based nursing, not public health nursing, involves administering care for a defined geographic community.

The focus of community-based care is: o providing care to clients within a defined geographic area. o providing appropriate care for mental health. o providing population-based care of the entire community. o promoting the health of the nation.

o providing care to clients within a defined geographic area. · Community-based care is health care provided to people who live within a defined geographic area; it is not focused on promoting the health of the nation. It centers on individual and family health care needs for acute and chronic health problems. It is not focused on mental health problems. In contrast, public health nursing and community health nursing are population-based and focus on the needs of the community.

When a client is admitted to the hospital, admissions personnel are required to determine whether the client has a document indicating advanced directives. If so, a copy is made for the client's medical record. The advanced directive document indicates: o that the client assigned a relative to act on the client's behalf. o that the client has made wishes for terminal care known. o that an attorney has verified the living will papers. o that the client refuses to have resuscitation measures or any life-prolonging care.

o that the client has made wishes for terminal care known. · It is important to determine whether the client has advanced directives, which indicate the client's wishes regarding future care should the client become unable to communicate them. Advanced directives may be documented in a living will or a durable power of attorney for health care document. A copy should be placed in the client's hospital record. Simply having an advanced directive only means that the client has expressed some wishes regarding terminal care, not necessarily that an attorney has verified the document, that the client has refused to have resuscitation measures or any life-prolonging care, or that the client has assigned a relative to act on the client's behalf, although any or all of these could be true.

A 15-year-old Vietnamese-American boy has been referred by his homeroom teacher to the school nurse for evaluation. The teacher is concerned that the adolescent may be suffering from major depression. When investigating these concerns at the family's primary care office, the nurse would use which person as the primary source of information? o the client o the client's homeroom teacher o the client's school nurse o the client's parents

o the client · The client is the primary historian, and the nurse should first elicit his perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with the adolescent may have been minimal. The client's parents can provide insight and assistance, but they may not be willing to do so because of cultural differences. The teacher will provide a valuable timeline and observations as the individual who referred this case; however, the client is still the primary historian.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? o Registered nurse first assistant o Scrub nurse o Circulating nurse o Surgeon

o Circulating nurse · The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? o Document the data for future reference. o Continue to collect assessment data. o Contact the client's health care provider. o Consult with a more experienced nurse.

o Consult with a more experienced nurse. · A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The nurse must document the data, but if the data are significant and the nurse does not recognize this and takes no action, it could harm the client. There is no need to contact the health care provider at this time.

Home health care nurses are required to complete the Outcome and Assessment Information Set (OASIS) by which entity? o Any third-party payer o Any insurance company o Medicare o Medicaid

o Medicare · OASIS provides standardized guidelines for admission and care, as well as a national database for evaluation, reimbursement, and quality improvement. The OASIS system of data collection is required by Medicare, not by Medicaid, insurance companies, or any other third-party payer.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? o SOAP o MAR o SBAR o PIE

o SBAR · The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.