PN Management B

A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first?

A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent

A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients?

A client who has burns to the trunk and legs

A nurse is assisting with the selection of client to discharge to make beds available following a tornado in the community. Which of the following clients should the nurse recommend for discharge

A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago

A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first?

A preschooler who has respiratory syncytial virus and is wheezing

A nurse is assisting with the development of a presentation for newly licensed nurses regarding client confidentiality. Which of the following actions should the nurse include as an example of a breach of client confidentiality?

Accessing client medical records from other units to compare outcomes with currently assigned clients

A nurse is planning to delegate care for a group of clients following change-of-shift report. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)?

Applying bilateral sequential compression devices to a client's legs

A nurse is completing documentation on the computer at the nurse's station when an assistive personnel (AP) requests to use the computer to enter morning vital signs. Which of the following actions should the nurse take?

Ask the AP to find another computer.

A nurse at a rehabilitation facility is supervising a newly hired assistive personnel {AP} during the transfer of a client from the bed to a chair. Which of the following actions by the (AP) during the transfer of the client

Bends at the knees

A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 200. Which of the following recommendations should the committee make?

Check on clients hourly

A nurse is assisting with the discharge of a client who was in a motor-vehicle crash 24 hr ago. The client tells the nurse "My vision seems blurry, and I am having difficulty speaking clearly." Which of the following actions should the nurse take first?

Check the client for indications of increased intracranial pressure.

A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. The client has a new diagnosis of diabetes and his partner is at the bedside. Which of the following actions should the nurse take?

Contact an interpreting service via telephone to assist with the instructions.

A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take?

Encourage each staff to give up something as part of the negotiation

A nurse is discussing time management with a newly licensed nurse. Which of the following actions should the nurse recommend to organize daily assigned client tasks?

Establish goals

A charge nurse is discussing legal issues with a newly licensed nurse. Which of the following actions should the charge nurse identify as negligence?

Failing to provide one-to-one observation for a client who is suicidal.

A nurse is assisting an RN with a developing a meal plan for a client who has neutropenia. Which of the following foods should the nurse recommend to include?

Fried Fish

A nurse in a long-term care facility is caring for a client who is refusing his prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about taking the medications.

A nurse is observing an assistive personnel (AP) provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks?

Making a surgical bed for a client returning from surgery

A nurse is caring for a client who has COPD. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measuring the client's weight

A nurse realizes she has administered the wrong medication to a client. Which of the following actions should the nurse take first?

Monitor the client's vital signs.

A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurse should identify that which of the following procedures require an additional written informed consent?

Performing an amniocentesis

A nurse in a long-term care facility is preparing to demonstrate administration of a cleansing enema to a group of newly licensed nurses. Which of the following actions should the nurse plan to take during the demonstration?

Place the client in a left side-lying position

A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for the client at home?

Portable suction

A nurse is assisting with the development of an in-service about the process of evidence-based practice. Which of the following actions should the nurse include as the first step of this process?

Question a current clinical practice that does not seem effective.

A charge nurse notices a nurse on the unit arriving to work 30 minutes late. The nurse appears unkempt and has slurred speech. Which of the following actions should the charge nurse take first?

Reassign the nurse's clients to another nurse.

A nurse is reinforcing teaching with a newly licensed nurse about ethical principles to consider during client care. Which of the following actions should the nurse include as an example of client advocacy?

Relaying a client's concerns about an upcoming procedure to the provider

A nurse is supervising an assistive personnel (AP) fax a client's morning laboratory results to a provider's office. Which of the following actions by the AP requires intervention by the nurse?

Sends laboratory results from the past week

A nurse is assisting with the care of an older adult client who is recovering from a stroke and is experiencing difficulty swallowing and performing ADLs. The client will be living with his adult son following discharge. The nurse should recognize that which of the following client referrals has the highest priority?

Speech Therapy

A nurse is collecting data from a client following abdominal surgery. The nurse should recognize which of the following client findings is the priority to report to the provider?

Surgical dressing saturated with bloody drainage.

A nurse assisting with disaster triage is examining a client who has a large open wound to the lower extremity. Which of the following actions should the nurse take?

Tell the client she should receive treatment within 2 hr.

A nurse at a rehabilitation facility is participating in an interprofessional care conference for a client who is 1 week postoperative following an above-the-knee amputation. Which of the following findings is the priority for the nurse to report at the conference?

The client's incision site has purulent drainage.

A nurse is contributing to the plan of care for a group of clients. Which of the following scenarios demonstrates effective use of time management?

The nurse groups activities for a surgical client based on the client's pain medication schedule.

A nurse is caring for a client who is recovering following a total hip arthroplasty. The nurse receives a telephone call from the client's sister requesting information about the client's status. Which of the following actions should the nurse take?

Transfer the call to the client

A nurse assisting with the care of a client who suddenly becomes unconscious and requires emergency surgery. The client does not have advance directives and the only family member available is the client's 14-year-old daughter. Which of the following actions should the nurse plan to take?

Transport the client to the operating room with implied consent.

A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides?

Use sentences that have a maximum of six words.

A nurse is participating in a peer evaluation system based on overall performance of its nursing staff. Which of the following strategies ensures that the peer evaluation is impartial and fair?

Uses the same objective measurement tool for all nurses

A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first?

Verify the medication with the client's medication administration record (MAR).

A newly hired nurse recognizes that the unit staff and nurse manager seem to be in constant conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches when she decides that her plans are best and the unit staff is no longer trying to resolve conflict>

Win-Yield

A nurse is delegating a collection of a random stool specimen to an assistive personnel (AP), which of the following information should the nurse provide?

Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal.

A nurse is contributing to the plan of car for a client who states he is a devout Hindu. To adhere to the client's religious dietary practices, which of the following food options should the nurse offer to the client?

Yogurt

A nurse is delegating tasks to an assistive personnel (AP), Which of the following statements by the nurse includes the five rights of delegation?

"Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath."

A nurse is reinforcing teaching about home safety with an older adult client. Which of the following client statements indicates an understanding of the teaching?

"I should participate in a supervised exercise program."

A nurse is assisting with a presentation about preparing a home disaster supply kit at an community health fair. Which of the following statements by a participant should the nurse identify as understanding of the information?

"I will purchase canned fruit for the kit."

A nurse is verifying informed consent with a client who is scheduled to have a total open abdominal hysterectomy with bilateral salpingo-ooophorectomy for the treatment of uterine cancer. The nurse should notify the provider for which of the client statements?

"I wish I knew if there was another way to treat this other than surgery."

A charge nurse in a skilled care facility identifies an increased rate of client falls. Which of the following statements to the nursing staff indicates the charge nurse is addressing the problem with an autocratic leadership style?

"I've made it mandatory for all nursing staff to attend an educational session on reducing client falls."

A newly licensed nurse is caring for a client who requires a straight catheterization. The nurse informs the charge nurse that he has only observed the procedure on two occasions. Which of the following responses should the charge nurse make?

"Let's discuss the procedure and I'll assist you with it the first time."

A nurse in a provider's office is reinforcing discharge teaching with an adult client who has a new prescription for ear drops for an inner ear infection. Which of the following instructions should the nurse include?

"Lie on your side when preparing to instill the ear drops."

A nurse is discussing the meaning of the utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this ethical theory?

"Utilitarianism provides the greatest good for the greatest number of people."

A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse include? (select all that apply)

*Administer furosemide 40 mg PO daily *Apply oxygen to keep SpO2 greater than 95% *Obtain daily weight

A nurse is assisting with the admission of a client who reports that she signed advance directives during a previous admission. Which of the following actions should the nurse take? (Select all that apply)

*Document in the client's medical record that she has advance directives *Ensure that copies of the client's advance directives are located in her chart *Inform the oncoming nurse of the client's advance directives during change-of-shift report

A charge nurse is planing a discussion concerning scope of practice with a newly licensed nurses. Which of the following tasks should the charge nurse identify as within the PN's scope of practice? (select all that apply)

*Participate in health promotion counseling for a client *Evaluate a client's response to nursing interventions *Assist in the development of unit policies affecting client care