CBA Level 5 Practice B
a nurse manager is developing an in service for staff members about the emergency medical treatment and active labor act (EMTALA) which of the following information should the nurse manager include
EMTALA violations can lead to loss of medicare payments
a nurse is teaching a newly licensed nurse how to perform assisted coughing for a client who has a spinal cord injury. in what order should the nurse perform the following steps
*Place hands on the PT's upper abd c fingers interlocked *Instruct the PT to take a breath then cough while exhaling *Lock the elbows *Push hands inward & upward *Allow the client to rest
a nurse manager is discussing professional liability during a staff presentation. in which of the following situations can the assigned nurse be held professionally liable if the client is harmed SATA
*a charge nurse insists a staff nurse reposition a sutured NG tube etc, *RN admins. warfarin to a PT with an INR of 4.3 *A client experiences an arrhythmia while the RN tries for hours to report a K to the HCP but does not notify the charge nurse
a case manager is planning care for a middle adult client who was moderately injured during a work accident. the client has dependent children and reports needing financial assistance to pay for healthcare. which of the following resources should the case manager recommend? (select all that apply.)
*medicaid *state workers compensation board *local health department
A charge nurse is supervising a group of staff on the unit. Which of the following actions should the charge nurse ID as a potential professional liability?
A nurse requests to perform the narcotic count every shift.. This can be a characteristic of a chemically-impaired nurse.
a nurse in an emergency department is caring for a client who has persistent supraventricular tachycardia with manifestations of shortness of breath and syncope. which of the following medications should the nurse expect the provider to prescribe to convert this dysrythmia to normal sinus rhythm
Adenosine. Adenosine can interrupt an acute episode of SVT and convert it to normal sinus rhythm. The nurse should administer it rapidly by IV bolus and then flush the IV catheter with 20 mL of 0.9% sodium chloride.
A charge nurse on a medical-surgical unit is working with a licensed practical nurse (LPN). Which of the following tasks should the nurse assign to the LPN
Administer an IM pain medication to a postoperative client
A nurse is reviewing the medical record of a client who had a myocardial infarction (MI) and is to undergo a cardiac catheterization. Which of the following information should the nurse report to the provider prior to the procedure
Allergies. RN should recognize that the use of some supps like garlic, fish oil, or ginkgo biloba, can increase the risk of bleeding following an invasive procedure such as a cardiac catheterization.
a nurse is evaluating quality improvement tools at a facility. when reviewing information about clients who had sepsis, which of the following data should the nurse identify as indicating improved client outcomes
An in increase in the # of clients who did not require vasopressor admin to treat a MAP above 65. The nurse should recognize that sepsis decreases cardiovascular output. Clients who are successfully treated with fluid replacement do not require vasopressor administration. Therefore, the nurse should ID that the expected reference range for MAP is 60 to 70 mm Hg and indicates an improvement in quality of care.
a nurse is assessing a client who has hepatic encephalopathy and a serum ammonia level of 110 mcg/dL. which of the following images depicts the test the nurse should implement to determine whether the client is in stage IV of hepatic encephalopathy?
Babinski. The nurse should identify that the Babinski sign or reflex is present in an adult client who has neurological changes due to hepatic encephalopathy. Other manifestations of stage IV hepatic encephalopathy: seizures or absent response to painful stimuli.
a public health nurse is investigating a potential outbreak of measles in the community. which of the following agencies should the nurse ID as a resource for reporting a potentially infectious outbreak of measles.
CDC
A nurse in the emergency department is caring for a client who sustained major burns in a house fire. Which of the following interventions is the nurse's priority.
Check for singed nasal hairs
a public health nurse is participating in the recovery phase of emergency response to a hurricane. Which of the following actions should the nurse take first?
Determine the needs of the community. The first action the nurse should take using the nursing process is to assess data and establish the needs of the community.
a nurse is reviewing the medical record of a client who has sepsis and is experiencing septic shock. which of the following findings should the nurse expect?
HR 116. The nurse should expect a client who is experiencing septic shock to exhibit tachycardia as a compensatory response to decreased cardiac output. A client experiencing septic shock will exhibit a fluid volume excess with edema due to vasodilation and fluid shifts within the body & will exhibit absent bowel sounds caused by ischemia from decreased cardiac output.
A nurse is discussing hepatitis C with a newly licenses nurse. Which of the following information should the nurse include?
Hepatitis C frequently results in a chronic infection, The nurse should include that a hepatitis C infection often causes no symptoms and is not diagnosed until months or years following infection. Most clients develop a chronic infection.
a nurse is teaching a client who has AIDS about self-mangement strategies for preventing infection. Which of the following client statements indicates an understanding of the teaching?
I should not share deodorant sticks c others. To help prevent infection immunocompromised should not share deodorant sticks c other people due to possible transmission of micro-organisms. To help prevent infection, they should bathe daily c antimicrobial soap & avoid foods that are not thoroughly cooked like raw fruits and vegetable, undercooked meats and eggs, and raw fish.
A nurse is providing discharge teaching to the parent of a preschooler who experienced a minor head injury after a fall. Which of the following statements by the parent indicates an understanding of the teaching
I should notify the provider if my child develops a runny nose in the next several days. The nurse should instruct the parent that clear fluid leaking from the nose can indicate leaking of cerebral spinal fluid due to a skull fracture.
a nurse is contemplating accepting a nursing leadership role as a charge nurse on his unit. which of the following statements by the nurse indicates an understanding of a charge nurse's role?
I should review the facility's chain of command and invoke the process when needed
A nurse manager is conducting quality improvement audits for the unit. Which of the following findings requires further evaluation
Increased client falls
A nurse is planning care for a client who is experiencing Addisonian crisis and has hyperkalemia. According to research-based care, which of the following interventions should the nurse include in the plan?
Initiate cardiac monitoring for the client. Research-based care indicates that the nurse should place the client on a cardiac monitor to assess for manifestations of hyperkalemia, such as bradycardia; irregular rhythm; tall, peaked T waves; and heart block, which can progress to asystole.
a nurse in the emergency department is caring for a client who is experiencing an acute myocardial infarction (MI) and reports chest pain that has an intensity of 8 on a scale of 0-10. Which of the following medications is the nurse's priority to administer to this client
Morphine. The greatest risk to a client who is experiencing an acute MI is further injury to the heart from inadequate oxygenation and perfusion. Therefore, the priority is for the nurse to administer opioid analgesia to manage the client's pain and thus increase oxygenation, decrease myocardial oxygen demand, and relax smooth muscles.
a nurse working in an industrial facility is providing care for a worker who experienced a hazardous chemical exposure. to which regulatory agency must the nurse report this incident
Occupational Safety and Health Agency
a nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP
Performing chest compressions as a member of the CODE team. The nurse should delegate performing chest compressions because this is within the range of function for an AP. This task does not require the use of the nursing process or clinical judgment.
a nurse is assessing a client who has cushing's disease. which of the following manifestations should the nurse expect?
Pincreased blood pressure. The nurse should expect a client who has Cushing's disease to have HTN. Cushing's disease causes the client to retain sodium and water, which causes edema and increases blood pressure.
a nurse manager at a home health facility is preparing an in-service about legal guidelines. which of the following situations should the nurse plan to include as an example of medical malpractice
RN forgets to request PT services for a PT who has weakness & they fall. One role of the home health RN is to connect a client c services. In this situation, the nurse should have recognized the potential for harm & taken actions to prevent injury. This situation might be considered medical malpractice because the nurse failed to take reasonable action to prevent harm.
a nurse is assessing an adolescent who is experiencing hypovolemic shock. which of the following findings should the nurse expect
RR 26. Others: Tachycardia; weak peripheral pulses due to decreased CO & blood volume; cap refill >2 seconds.
A nurse is reviewing laboratory reports for a client who has sepsis and has been receiving IV antibiotics for 2 days. Which of the following laboratory results should the nurse report to the provider immediately
WBC 45,000. When using the urgent vs nonurgent approach to client care, the RN should determine that a WBC count of 45,000 is the priority finding because it is a critical value that indicates widespread inflammation, known as systemic inflammatory response syndrome, and should be reported to the provider immediately.
a charge nurse is discussing accrediting organizations for health care facilities with a newly licensed nurse. which of the following statements about the joint commission should the charge nurse take
the joint commission requires facilities to follow quality improvement initiatives
a nurse is receiving change of shift report about four clients. for which of the following clients should the nurse suspect physical abuse
a 3-year-old child who has a burn on the sole of the right foot. The nurse should identify that a burn on the sole of the foot is an indication of potential child maltreatment in the form of physical abuse and should be reported.
A public health nurse is leading an in-service about types of health care services in the community. Which of the following should the nurse include as an example of secondary care?
a client in a diagnostic center who is receiving a CT scan to check for a tumor. Secondary care includes screening for and early treatment of conditions.
a charge nurse is discussing sentinel events with a newly licensed nurse. which of the following example should the nurse provider as a sentinel event
a client who falls experiences a subarachnoid hemorrhage. A sentinel event is an occurrence that leads to injury, coma, or death or places a client at risk for these outcomes.
a nurse is performing mass casualty triage following a disaster. To which of the following clients should the nurse assign a black tag
a client who has a penetrating head wound and agonal respirations. The nurse should assign a black tag to a client who has died or is expected to die due to injury.
a nurse at a community health clinic is assisting in the mass casualty triage of clients following an explosion. to which of the following clients should the nurse assign a green tag
a client who has an upper extremity closed fracture. The nurse should assign a green tag to a client who has minor injuries, such as a closed fracture of an extremity, and can wait several hours to days for treatment
a nurse is caring for a group of clients on a medical-surgical unit. which of the following client situations should the nurse report to the charge nurse as a near miss
a client who is NPO receives a meal tray and the AP removes it before the client eats or drinks anything. The RN should recognize that a near miss is a situation where an error occurs but the client experiences minimal to no harm
a nurse manager is teaching a group of newly licensed nurses about clients having autonomy. which of the following examples should the nurse manager include that demonstrates this ethical principle?
a nurse respects a client's decision to refuse the administration of blood due to religious beliefs
a nurse is teaching a group of unit nurses about lung surfactant therapy to treat respiratory distress syndrome in preterm newborns. which of the following information should the nurse include
administer the medication via endotracheal instillation. The nurse should include that lung surfactant is administered via endotracheal instillations to reinflate collapsed alveoli by lowering surface tension of the surrounding fluids
a nurse is caring for a client who has bipolar disorder. which of the following actions indicates the nurse is respecting the client's right to privacy
asking family members to leave the room before the medical history is collected from the client
a nurse is providing education for a female adolescent regarding self management of systemic lupus erythematosus. which of the following information should the nurse include
increase consumption of calcium rich foods. SLE & TX with glucocorticoid steroids increase the risk of the client developing osteoporosis. The client should increase her intake of calcium and vit D. Supps can be added if dietary intake is inadequate.
a nurse is planning care for a client who is postoperative following abdominal surgery. According to research-based care, which of the following interventions should the nurse include in the plan to prevent a deep-vein-thrombosis
admin prophylactic anticoagulant to the client
a nurse is planning care for a client who is being admitted with a major burn injury over 40% of the total body surface area. which of the following interventions should the nurse include in the plan
admin. continuous IV fluids for 24hr. The nurse should administer continuous IV fluids for 24 hr. The nurse should administer half of the total volume prescribed for the 24 hr period within the first 8 hr. The remaining volume should be infused over the next 16 hr.
a nurse is caring for a child who has bacterial meningitis with increased intracranial pressure. which of the following actions should the nurse take
administer acetaminophen with codeine for pain. The nurse should plan to administer acetaminophen with codeine to treat the child's pain and fever due to the risk of complications of bleeding should the child develop meningococcal sepsis.
a nurse is caring for a client who has developed cardiogenic shock. which of the following is the nurse's priority
administer oxygen. Clients who have cardiogenic shock are at high risk for inadequate oxygenation and perfusion.
a nurse in a primary care clinic is examining the ECG tracing of a client who reports fatigue and palpitations. the nurse notices no visible p waves, no atrial contractions, a wavy baseline and an irregular ventricular rate. which of the following dyrythmias should the nurse identify
atrial fibrillation. These ECG findings are indications of atrial fib which is a common dysrhythmia in clients who have HF, coronary artery disease, or HTN. Rapid, disorganized impulses from the atria create a chaotic rhythm that reduces cardiac output and perfusion.
a nurse is assessing a client who has AIDS. the client reports persistent diarrhea with rapid weight loss. Which of the following opportunistic infections should the nurse expect
cryptosporidiosis. The nurse should ID that candidiasis is a fungal infection that, for clients who have AIDS, causes stomatitis or esophagitis. Manifestations include mouth & substernal pain, difficulty swallowing, changes in taste, & yellowish-white patches on mucous membranes.
a nurse is teaching about home care with the guardian of a child who has thrombocytopenia and a platelet count of 40,000. which of the following statements by the guardian indicates an understanding of the teaching
i will give my child acetaminophen when she is having pain. The guardian should administer acetaminophen if the child is experiencing pain. Analgesics such as aspirin and NSAIDs increase the risk for bleeding and should be avoided.
a nurse is updating the discharge plan for a client who is ventilator-dependent and will be transferred to a long-term care facility. To facilitate the coordination of the transfer, the nurse should contact which of the following members of the health care team?
case manager. The nurse should contact the case manager, who will coordinate all aspects of the transfer to a long-term care facility.
a nurse manager discovers that the unit is over budget for the quarter. which of the following actions should the nurse manager plan to take to provide more cost-effective care
consider labor requirements during the past year before determining staffing needs. This can help the manager determine how money might need to be allocated to better meet the next quarter's budget.
a nurse manager is planning to assist two staff members involved in a conflict by using the conflict management strategy of third-party consultation. which of the following actions should the nurse manager plan to take?
consider the assistance of outside experts for highly emotional situations
a nurse is providing an in-service for a group of newly licensed nurses about professional characteristics. which of the following should the nurse include as an example of the nursing value of altruism
considers the well being of coworkers. By considering the well-being of coworkers, the nurse is demonstrating the professional characteristic of altruism. Altruism involves taking actions that take into account the needs and well-being of others.
a nurse manager is teaching about emergency preparedness to a group of newly licensed nurses for clients who experience mental health crises following a disaster. which of the following actions should the nurse include in the teaching as the first step to take when caring for these clients?
determine the clients' level of precrisis functioning
a nurse is assessing a client who is a resident of a halfway house for clients who have mental health disorders. the client has patterned bruising to the torso and arms. which of the following actions should the nurse take
develop rapport with the client. By developing rapport during the pre-interaction phase of the nurse-client relationship, the nurse promotes trust with the client and helps the client feel comfortable about disclosing personal info to the nurse.
a nurse is working on a postpartum unit to implement 24 hr rooming-in for mothers and their infants. which of the following actions by nurse demonstrates the preparation stage of the stages-of-change model?
developing a presentation for staff members about 24 hr rooming-in
a nurse is assessing a client who has systemic lupus erythematosus (SLE). which of the following manifestations should the nurse expect
dry scaly rash over the nose and cheeks. The nurse should expect a client who has SLE to exhibit a dry, raised, scaly rash on the face, also known as a "butterfly rash." The rash can also appear on other areas of skin that are exposed to the sun.
a nurse is reviewing the medical record of a client who has cirrhosis due to liver disease. which of the following laboratory findings should the nurse expect
elevated serum bilirubin. The nurse should expect a client who has cirrhosis due to liver disease to have an elevated serum bilirubin level due to the liver's inability to excrete bilirubin. The expected range for serum bili is 0.3 to 1
a nurse is reviewing the medical record for a client who has addison's disease. which of the following laboratory results should the nurse expect
fasting blood glucose 62. The nurse should expect a client who has Addison's disease to have hypoglycemia. The nurse should identify that a fasting blood glucose of 62 mg/dL is below the expected reference range of 70 to 110 mg/dL, which indicates hypoglycemia.
a nurse is assessing a client who has a stage III pressure ulcer. which of the following findings should the nurse expect?
full thickness tissue loss with visible subcutaneous fat. The nurse should identify that full-thickness tissue loss with visible subcut fat is a manifestation of a stage III pressure ulcer. Other manifestations include possible undermining or tunnelling and the presence of slough.
A nurse is assessing a client who has a brain tumor. The client has difficulty balancing due to poor muscle coordination and the nurse detect nystagmus. The nurse should recognize that the brain tumor is affecting which of the following areas of the brain?
green one, the cerebellum. This is the portion of the brain known as the cerebellum. Cerebellar function includes control of gait and equilibrium. Therefore, the nurse should ID that ataxia, or difficulty walking, with significant muscle incoordination as indications that the brain tumor is affecting the cerebellum. Other expected findings of a tumor in this region of the brain include dizziness and nystagmus.
a nurse is assessing a client following surgery. for which of the following manifestations should the nurse suspect that the client has a pulmonary embolism
hemoptysis. The nurse should ID that hemoptysis is a manifestation of a PE as a result of acute pulmonary hypertension & infarction. Other manifestations: tachypnea, chest pain, apprehension, low-grade fever, pleural friction rub, cyanosis, diaphoresis, S3 and S4 heart sounds, petechiae over the chest and axillae.
a nurse is teaching a client who has just undergone the insertion of a permanent pacemaker because of a sinus dysryhtmia. which of the following instructions should the nurse include
hold cell phones to the ear on the opposite side of the pacemaker. Hold cell phones to the ear on the opposite side of the pacemaker. Cell phones should be at least 15.2 cm (6 in) away from the pacemaker's generator at all times. The client should be sure to hold cell phones on the side opposite the pacemaker.
a staff nurse who is upset approaches a charge nurse about concerns related to providing care to a group of clients. which of the following statements should the charge nurse make when using assertive communication
i am willing to discuss this issue privately in my office
a nurse is caring for a client who is experiencing chronic pain due to terminal cancer. the client asks the nurse to administer an injection to help him die. which of the following responses should the nurse make regarding this ethical dilemma
i can assist you with establishing advance directives that will clarify your end of life wishes
a nurse who is following the chain of command reports an ongoing issue regarding a documented unsafe client care practice to her nurse manager. which of the following responses should the nurse manager make?
i will work with you to take this issue to the next level as we attempt to enact change
a nurse is developing a plan of care for a toddler who has heart failure and is receiving furosemide. which of the following actions should the nurse include in the plan
increase the toddler's intake of foods high in K+. The nurse should ID that furosemide causes increased excretion of K+, which can lead to hypokalemia. Therefore, the nurse should increase the toddler's intake of foods high in K+ like bananas, sweet potatoes, and tomatoes.
a nurse is assessing a client who has encephalitis. the nurse should ID that which of the following findings is an indication of increasing intracranial pressure
increased pupil size. The nurse should recognize that increased pupil size or pupils that become less responsive to light are both changes that can indicate ICP. Without intervention, increasing ICP can lead to brain herniation and death. The nurse should immediately notify the HCP if this manifestation occurs.
a nurse in an emergency department is triaging an older adult female client who has a history of coronary artery disease. the client is reporting vague manifestations but no chest pain. which of the following findings should the nurse identify as a possible manifestations of an acute myocardial infarction
indigestion. Many older adults who are experiencing an MI believe that their epigastric distress is indigestion and do not suspect that it is a possible indication of an MI. Other manifestations that can indicate an MI in the absence or presence of chest pain are diaphoresis, nausea, dyspnea, and anxiety.
A nurse manager is conducting an in-service about hepatitis A for a group of nurses. Which of the following information should the nurse manager include as a risk factor for acquiring the hepatitis A virus
ingesting shellfish. The nurse manager should include that hep A comes from contaminated food and water. Shellfish caught in contaminated water can carry the virus. It can also be transmitted by contaminated food handled from person to person. Another route of transmission for hep A is the fecal-oral route.
a nurse is caring for a newborn who has delivered after a prolonged rupture of membranes. which of the following newborn assessment findings should the nurse report to the provider
intercostal retractions. Intercostal retractions can be a manifestation of a neonatal infection. The most common neonatal infection is pneumonia. The presence of retractions indicates increased resp. effort as does grunting, nasal flaring, and tachypnea.
a nurse is planning a presentation about professional nursing organizations. which of the following information should the nurse include about the ANA
it develops professional standards for nursing practice
a nurse is providing teaching to a client who has polycystic kidney disease (PKD) which of the following disease management instructrions should the nurse include
keep track of your bowel movements. instruct the client to monitor bowel activity to detect constipation because progression of PKD causes swelling of the kidneys, placing pressure on the intestines and colon. The nurse should also include prevention measures, such as adequate fluid intake and regular exercise, as a part of the teaching.
a public health nurse is reviewing the roles of local, state, and national agencies in emergency response. After first responders are dispatched to the site of an incident, which of the following actions should the nurse expect to occur next
local officials activate the local emergency operations center
a nurse is planning care for an infant who has bronchiolitis caused by respiratory synctial virus (RSV) which of the following interventions should the nurse include?
maintain oxygen saturation at 90% or greater. The nurse should suction the infant's nares and pharynx to maintain a patent airway and administer oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90%.
a nurse is teaching a group of clients about degenerative disk disease. Which of the following information should the nurse include regarding the prevention of low back pain and injury?
maintain weight within 10% of ideal body weight. The nurse should teach the clients to maintain their weight within 10% of ideal body weight. Clients who are obese have increased stress on the vertebral column and back muscles, placing them at an increased risk for injury.
a nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000 which of the following actions should the nurse take
measure the clients abdominal girth daily. The nurse should measure the client's abdominal girth daily to assess for internal hemorrhage. Manifestations of internal hemorrhage can include an increase in the client's abd size as well as blood in the stool or urine.
a nurse is planning care for a child following replacement of a ventriculoperitoneal shunt for treatment of increased intracranial pressure. which of the following interventions should the nurse include in the plan
monitor the child for abdominal distention. The drainage of cerebrospinal fluid from the VP shunt into the abd cavity can lead to peritonitis or a paralytic ileus in the postoperative period. Signs of peritonitis and paralytic ileus include progressive abd distention, pain, and a rigid abd
a nurse is assessing a client who has a brain tumor. which of the following findings should the nurse expect
morning headache. The nurse should expect a client who has a brain tumor to experience more severe headaches in the morning. Other manifestations include paralysis, nausea, vomiting unrelated to food intake, blurred vision, and seizures.
a nurse manager is reviewing conflict management strategies with a group of nurses. which of the following statements should the nurse include when discussing the strategy of smoothing
one party attempts to pacify the other party to minimize emotions. The nurse should include pacifying and focusing on agreements as characteristics of the smoothing strategy of conflict resolution.
a community mental health nurse is planning strategies to address increased opioid use in the community. which of the following strategies should the nurse implement as a method of primary prevention
organizing a town hall assembly to discuss the adverse effects of opioid use. The nurse should ID that primary prevention strategies focus on preventing opioid use disorder from ever starting. Providing education to clients in the community about the adverse effects of opioid use is intended to promote prevention of opioid use disorder among the target audience.
a nurse is assessing a client who has advanced stage cirrhosis. which of the following findings should the nurse expect? (Select all that apply.)
petechiae, pruritis, hemorrhoids
a nurse is developing a plan of care for a client who has a deep-vein thrombosis of the lower left leg. which of the following interventions should the nurse include
place thigh-high graduated compression stockings on the clients leg. The nurse should plan to apply compression stockings to the client's legs to enhance venous return and prevent pooling of blood in the lower extremities.
A nurse is reviewing the medical record of a client who experienced a T5 spinal cord injury (SCI) Which of the following findings should the nurse report to the provider immediately
platelet count 50,000. This level is below the expected reference range of 150,000 to 400,000/mm3 & might indicate a decrease in blood cell production. This can be a result of a lack of autonomic innervation to the blood-cell producing system, which can place the client at risk for bleeding.
a nurse is reviewing the medical record of an 11-year-old child who has acute renal failure. which of the following laboratory results should the nurse expect
potassium 5.2
A nurse is reviewing the laboratory results for a client who sustained major burns after a motor vehicle crash where a fuel spill ignited. Which of the following laboratory values should the nurse expect during the resuscitation phase of care
potassium 6.2. Tissue destruction and the hemolysis of RBCs elevate potassium levels during the resuscitation phase following burn injuries. During the resuscitation phase following burn injuries, Hgb increases due to fluid-volume losses.
A charge nurse is working on an acute care floor when a natural disaster occurs. Which of the following emergency response actions should the nurse take?
prepare medically stable clients for early discharge. The charge nurse should prepare medically stable clients for early discharge to allow open beds for clients who require immediate medical attention.
a nurse is reviewing the medical record of a client. Which of the following findings should the nurse identify as a risk factor for developing a DVT
prescription of oral contraceptives. The nurse should identify that the use of oral contraceptives can increase the risk for developing a deep-vein thrombosis, especially during the first 6 months of therapy.
a nurse is collaborating with a dietician about the dietary intake of an older adult male client who has stage IV pressure ulcer. which of the following adjustments to clients diet is the priority for optimal wound healing
protein at 2g/kg/day. According to evidence-based practice, nutrients that are vital to wound healing include vitamin A, vitamin C, zinc, and protein. The nurse should determine that 2 g/kg of protein per day is the priority nutrient to provide for optimal wound healing for a client who has a stage IV pressure ulcer.
a nurse is working at a community health center with clients who have limited socioeconomic resources. Which of the following actions should the nurse take as a primary prevention strategy to address health care disparities for these clients
provide free influenza immunizations
a nurse manager notices that a nurse has slurred speech and smells of alcohol. which of the following actions should the nurse manager take first
remove the nurse from the client-care work environment
a nurse is applying debriding enzymes to a client's stage IV pressure ulcer. which of the following actions should the nurse take?
secure the dressing over the ulcer with tape. The nurse should apply tape over the dressing to keep it in place, protect the ulcer, and to keep the enzyme from touching the surrounding skin because the enzymes can irritate the skin.
a nurse is assessing a client who has a spinal cord injury (SCI) and is experiencing autonomic dysreflexia. which of the following manifestations should the nurse expect
severe headache. The nurse should expect a client who is experiencing autonomic dysreflexia to exhibit a sudden, severe headache. Autonomic dysreflexia occurs in clients who have an SCI above level T6 & is triggered by a stimulus such as a full bladder. This stimulus causes a reflexive response by the SNS
a nurse is using evidence based research to develop a critical pathway for clients who have partial thickness burns. using the research utilization process the nurse should identify which of the following categories represents the best strength of evidence
systematic reviews of clinical trials
a nurse in an ICU is assessing a client who has cardiogenic shock resulting from post myocardial infarction heart failure. Which of the following findings should the nurse expect?
tachypnea. The nurse should expect a client who has cardiogenic shock to have tachypnea and hypotension due to poor left ventricular function, decreased cardiac output, and increased oxygen demand.
a nurse preceptor is observing a newly hired nurse during orientation to the facility. which of the following actions by the newly hired nurse should the nurse preceptor identify as fulfilling the role of change agent
talks with a group of coworkers about the benefits of a provider order entry system
a nurse is discussing the role of the rapid response team (RRT). with a newly licensed nurse. which of the following statements should the nurse make?
the RRT may be activated by a client's family members. The nurse should include that a nurse or a client's family member should activate the RRT if they detect a decline in the client's status, such as a decrease in BP or HR or a change in mental status.
a nurse is assessing a client who has multiple fractures due to a motor vehicle crash 2 weeks ago. for which of the following findings should the nurse engage in interprofessional collaboration with the physical therapists
the client has a nonblanchable, reddened area on the sacrum. The nurse should collaborate with the PT for a client who has a nonblanchable, reddened area on the sacrum. This finding indicates a stage I pressure ulcer. PT can contribute to the plan of care for this client by developing a wound TX plan to keep the ulcer from progressing or providing therapy for the wound if it develops further.
a nurse is participating in interprofessional collaboration regarding a client who is to be discharged to home following a stroke. which of the following information should the nurse provide the occupational therapist on the team
the client is experiencing difficulty using a spoon for self-feeding. The nurse should inform the OT that the client is experiencing difficulty with self-feeding. The OT is able to assist the client with becoming independent with ADLs.
a charge nurse is teaching newly licensed nurse about risk management. which of the following statements by the newly licensed nurse indicates an understanding of the teaching
the risk manager reviews incident reports to monitor system flaws. The nurse should include that the risk manager is responsible for the review of incident reports to monitor for system flaws that can lead to client injury or death.
a nurse is reviewing ethical dilemmas with a group of newly licensed nurses. which of the following information should the nurse include about ethical dilemmas
the situation requires a choice between multiple ethical principles. For a situation to be considered an ethical dilemma, it must present a problem that requires a choice between multiple ethical principles.
a nurse is planning to administer a new medication to a client. the nurse is using which of the following ethical principles when he is truthful about the adverse effects of the medication
veracity is being truthful. Fidelity is keeping your word/promise.
a nurse is assessing a client who has encephalitis. For which of the following findings should the nurse immediately notify the provider?
widened pulse pressure. A widened pulse pressure indicates that this client is at greatest risk for ICP and a deteriorating neurologic status. Therefore, this is the priority finding to report to the provider. Increased ICP can lead to herniation of brain tissue and possible death if not promptly treated.
a nurse is caring for a client who has parkinson's disease. which of the following instructions should the nurse include in the teaching about mobility
you should consider participating in a yoga class. instruct the client to participate in low-impact exercise, such as yoga and tai chi. These kinds of exercises help to improve mobility and can help elevate mood during the early stages of Parkinson's disease.
