VATI RN Leadership and Management 2019

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

Move the clients to an area of safety. The clients are at greatest risk for injury form flames and smoke inhalation.

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

Report pus-like drainage from the wound. Provide clear descriptions in terms the client can understand when providing written discharge instructions. Client is aware of what complications to report to the provider.

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

A client who is 1 week postoperative following a hip fracture. Priority for an interdisciplinary care conference to address physical therapy, occupations therapy, dietary consultation, and social services.

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

A client who is 2 days postoperative and has a urinary output of 500 mL/24hrs. This indicates an average urine output of about 20mL/hr., which is less than the expected reference range of 30mL/hr. This finding can indicate a fluid volume deficit, impaired kidney function, or impaired bladder tone which requires immediate assessment and intervention by the nurse.

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

A client who is postoperative and has respiratory rate of 10/min. A respiratory rate of 10/min is below the expected reference range of 12-20/min and can indicate that the client is experiencing an adverse effect from anesthesia or pain medication.

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

A client who is postoperative following a thyroidectomy and reports tingling around their mouth. The client could be experiencing hypocalcemia which can lead to tetany and respiratory distress. The nurse should assess the client for muscle twitching and respiratory distress and be prepared to administer IV calcium gluconate or calcium chloride.

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

A middle adult client who has a severed lower extremity. A client who has a traumatic amputation requires immediate intervention for survival.

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

A nurse reports a procedure was completed incorrectly by another nurse to the charge nurse. A nurse arranges for an interpreter for a client who speaks a different language. The nurse should report improper completion of a procedure to the charge nurse and complete an incident report describing the incident. Reporting to the charge nurse is an act of client advocacy, which allows the charge nurse to further monitor the clients condition and prevent negative outcomes. Requesting an interpreter for a client who speaks a different language than the nurse. An interpreter will facilitate understanding of the teaching and allow the client to communicate their needs to the nurse.

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

A private office with the door closed. Deliver the performance appraisal in a private setting and without interruption.

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

Abdominal distention. Along with pain can be an indication of a postoperative ileus that requires gastric decompression by insertion an NG tube along with low intermittent suction to relive the pressure in the clients abdomen and remove blood or fluid that might be in the GI tract. This will also provide comfort to the client.

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

Access computerized data correlating client acuity, staffing, and scheduling. Nurse managers have a responsibility to ensure that the staff delivers cost-effective, high-quality care. Collecting data that support decision making.

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

An older adult client who had a total knee arthroplasty 1 week ago. Recommend a client who is medically stable for early discharge from the acute care facility.

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

Apply moisturizing lotion to the clients skin after bathing. A client who has dry and irritated skin is at greater risk for skin breakdown and the development of pressure injury. The nurse minimize dryness by applying moisturizing lotions while the clients skin is moist after bathing.

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

Assessment. Current vital signs, pain level, and appearance of a wound dressing in the assessment section of the SBAR report.

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

Attempt to obtain a prescription for a different analgesic medication. Directly intervening on behalf of the client.

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

Check the client for injuries. Asses the client, for injuries and make sure vital signs are stable. The nurse should also notify the provider of the clients fall and the assessment findings.

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

Collaboration Collaboration involves both parties agreeing to work towards a common goal rather than individual goals to fins a mutually satisfying solution to the conflict. The goal becomes what is best overall, rather than what each individual wants or thinks is best.

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

Collect a urine sample for urinalysis.

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

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

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

Contacting a social worker to assist the client with daily meals delivery services. Client advocacy involves contacting available resources on behalf of the client.

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

Decline because nurses should not work when ill. Nonmaleficence holds that one should do no harm. Coming to work while ill with influenza can place clients and other staff members at risk for developing influenza.

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

Democratic leadership Democratic leadership is a style that involves two way communication and fosters teamwork, goal accomplishment, and the individual worth of each staff member.

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

Determine the unit staff's perception of the need for change. The first action using the nursing process is assessment. By determining the unit staff's perception of the need for change, the nurse manager will be able to implement effective change.

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

Document the findings for the provider. Always document factual assessment findings in the clients medical recorded and notify the provider of unexpected findings to ensure the client receives the required treatment.

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

Document the missed medication administration in the client's medical record. It is the responsibility of the nurse to record the facts of the missed medication administration in the clients medical record.

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

Document thoroughly any unusual behavior by the nurse. Collect reports from other employees, client concerns and observations, as well as statements detailing any related incidents that support the nurse managers suspicion that substances use may be involved. The nurse manager can then refer the nurse ot an employee assistance program.

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

Document within the medical record that the client has advance directives in place. The patient self determination act requires acute care facilities to have documentation in the medical record that a client has advance directives. The nurse should document the clients wishes for other health care workers who are caring for the client so that they understand the clients plan of care.

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

Formulate a sample staffing schedule covering 1 month. Include the staff in the process by formulating a sample staffing schedule covering 1 month so that the staff can view the schedule and provide feedback. Resistance to change is an integral part of the process of change. A common reaction to scheduling changes is a fear of loss of hours and lack of trust of the employer.

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

Functional nursing. Also called task nursing, involves the nurse manager breaking dawn the needs of the clients into tasks and assigning the tasks using the skill and licensure of each staff member appropriately and efficiently. This model of nursing is uncommon in acute care settings, except in crisis situations, or when there is a shortage in staffing numbers.

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

Green. Identify a client who has minor injuries that can wait for treatment, such as sprains, strains, closed fractures, and abrasions.

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

Gross negligence Gross negligence is an extreme breach of care with an intentional, reckless disregard of consequences. The nurse's actions were intentional and reckless, in opposition of the provider's prescription, and placed the client at risk for pain and injury.

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

I will assign the client to a room close to the nurses station. So the newly licensed nurse can closely monitor the client.

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

I will inform the provider of your decision. The nurse should recognize that the client has the right to refuse treatment at any time.

A nurse manger is working with a team to resolve an ethical dilemma. Which of the following steps should the team take to make an informed decision?

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

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

Implement interventions to ensure the clients safety. The charge nurse is accountable for supervision follow up, and interventions to safeguarded the client, as well as any corrective actions. After discovering a situation with potential client harm, the charge nurse first action should be those that promote clients safety and correct any harm done.

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

Inform the provider to ask the grandparent to provide consent. Inform the provider that the grandparent is the closest adult relative available for signing the informed consent. The closest adult relative can provide consent in an emergency situation when the clients parents or guardian are unavailable.

A charge nurse is observing a newly licensed nurse administer a unit of packed RBCs to a client. The charge nurse should identify the nurse has completed the procedure correctly when he completes the steps in which order?

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

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

Let the client know that he will be updated as soon as possible. The nurse should obtain permission from the client's partner to release health condition information to the client.

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

My health care proxy will make my health care decisions when I am no longer able. The client should discuss her health care wishes with the health care proxy while she is able.

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

Negotiate specific tasks to perform with the nursing supervisor. Specific tasks to perform in order to ensure the nurse is providing safe care at the nurse's level of training and competence.

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

Observe the AP's technique with the lift at random times throughout the day. This method of assessment also assists in determining the need for further education and staff development.

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

Observe the clients nonverbal expressions. Body language and nonverbal expressions can assist the nurse to determine the client understanding of the information.

A nurse is planning care for a client who has hemiparesis and dysphagia following a strike. The nurse should collaborate with which of the following members of the interprofessional team to assist the client with managing ADLs? SATA

Occupational therapist Physical therapist Speech language pathologist OT helps clients with physical limitations or disabilities gain an optimal level of independence to perform ADLs, such as bathing , dressing, grooming, and eating. PT can assess the clients strength and mobility, implement therapeutic strategies and teach new skills to help compensate for physical limitations to help manage ADLs. Speech language pathologist can perform an in depth assessment of the clients swallowing and communication abilities and teach clients strategies for eating safety and performing ADLs.

A nurse is providing care to a group of clients. Which of the following steps should the nurse plan to take to manage time effectively? SATA

Organize tasks around the priority needs of the clients. Create a list of all planned activities. Delegate tasks to assistive personnel. To decrease the risk of needs not being met in a timely manner. Create a list of all planned actives to ensure that they are meeting their goals and managing their time effectivity.

A nurse manager on a maternal newborn unit is completing a chart audit on discharged clients to evaluate the success of breastfeeding education by a lactation consultant. Which of the following types of audits is the nurse manager utilizing?

Outcome audit. Measure whether the services that nurses provide make any difference in a clients resulting health status.

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

Place clients in a negative pressure room. Active TB in private neg pressure room with a minimum of six air exchanges per hour. Air from the room is exhausted directly to the outside. The nurse should also wear an N95 mask prior to entering the room.

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

Plan in in-service program for the nurses about HIPAA privacy rules. Ask the nurses to stop discussing the clients protected health information. Inform the nurse manager about the confidentiality breach. It will reinforce the importance of protecting client confidentiality. Take immediate action to inform the nurses that they have breached the clients confidentiality and to stop sharing information about the client. It is possible that the nurses misunderstood their responsibility to adhere to HIPAA privacy rules. The nurse manager is the appropriate person to reteach these basic legal concepts and can assist in providing an in service.

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

Put on a gown when caring for the client. C. difficile requires contact precautions.

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

Request the client sign an AMA form. Notify the provider of client's intent. Advise the client about the dangers of leaving. A signed AMA form can assist with a counterclaim of negligence. The nurse should immediately notify the provider of the clients intent to leave AMA. The nurse should discuss the potential dangers of leaving AMA, such as complications of the clients medical condition.

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

Respite care. Respite care services provide time away from caregiving responsibilities to attend to errands, needs, or social activities. An alternative caregiver, provided by respite care services, can care for the client temporally at home. This make sit possible for a long term caregiver or partner to step away from providing care for the client while still knowing that eh client will receive the necessary care.

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

Speak with the nurse regarding the incident. Evidence based practice indicate the nurse manager should first provide a verbal waring to the nurse as the initial step of the progressive disciplinary process. This allows the nurse manager to meet with the nurse privately to address the behavior and explain why this conduct is unacceptable. If the remaining steps of the progressive disciple process become necessary, the nurse manager will give written reprimand, then a suspension, and finally the nurse manger will terminate the nurse if the behavior does not change.

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

The client has difficulty grasping eating utensils. OT assists client with fine motor skills, often related to performing ADLs.

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

The client is reporting a pain level of 8 on a scale from 0 to 10. This information provides a brief explanation of the current situation and is part of the situation portion (S) of the SBAR communication tool.

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

The hospice team will provide services for the entire family, not just my father. Hospice services are provided by a team of health care professionals and nonprofessional that offer a full range of services, supporting both the client and family through the dying process.

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

The provider should periodically evaluate the DNR order. An revise it if the clients condition changes.

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

Use a formalized system to discuss important issues. Formalized system to determine the employees level of meeting the objectives for their job. The goal of performance appraisal is to promote growth for the employee and provide recognition for areas of strength along with feedback for areas of concern.

A nurse is caring for a client when they erroneously administer a medication dosage that is greater than the amount prescribed. Which of the following ethical principles is the nurse demonstrating when they notify the provider of the medication error?

Veracity. Holds that one should tell the truth.

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

When you come to work late, I am concerned that client care will be jeopardized. Assertive communication focuses on the impact the staff nurses behavior has on the function of the unit.

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

Would you like to speak with the provider again? When witnessing informed consent, the nurse is responsible for notifying the provider if the client has questions or appears not to understand any of the information about the surgery.

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

Zolpidem 5mg PO at bedtime.