EAQ 1
A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response?
A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.
A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly?
Provide constructive feedback.
A nurse uses flow charts to determine the usefulness of bed-monitoring devices for checking on dementia clients. Which Quality and Safety Education for Nurses (QSEN) competency does the nurse comply with?
Quality improvement
The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound?
Red
Which nurse is using complex critical thinking skills when caring for a client?
The nurse talks to the client to identify reasons for a particular behavior.
What was the goal of the Executive Order Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator?
To develop a nationwide health information technology system
A client is admitted to the postanesthesia care unit after abdominal hysterectomy. Which assessment should the nurse report to the primary healthcare provider immediately?
Decreased urine output
A client after a trauma has difficulty opening his or her eyes to pain, has abnormal flexion motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number.
8
A client requires emergency cardiac surgery. The leader nurse wants to make the client aware of the situation and wants the client to decide what should be done. Which ethical model does the leader nurse follow here?
Autonomy model
The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP?
Client C - monitor wound discharge after pt underwent ileostomy
The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation?
Delegation
While responding to a fire in a healthcare facility, which intervention made by the facility personnel would the nurse feel is inappropriate?
Exposing themselves to risk of injury by attempting to extinguish the fire
A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention?
Immobilize the client's head and neck.
Which is an indirect nursing care intervention?
Managing the client's environment
The nursing manager is evaluating the actions of charge nurses on different units of the hospital. Which charge nurse is providing high-quality care to the clients?
Orthopedics - performs work with fewer resources. ensures that transition of patients between the departments is respectful and efficient
A client whose medical expenses are covered under Medicare is hospitalized. Which component of Medicare can be claimed?
Part A
A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription?
Recognizing that PRN prescriptions for restraints are unacceptable
The primary healthcare provider confirms that the client has myopia. Which type of test did the nurse perform to help the primary healthcare provider reach this conclusion?
Snellen eye chart
A client is admitted to the hospital because of multiple chronic health problems. What is the priority intervention at this time?
Conducting a multidisciplinary staff conference early during the client's hospitalization
Which question does the registered nurse recognize as related to the right of circumstance when delegating?
"Is the delegation appropriate to the situation?"
Which care activities would be involved in a correct delegation process? Select all that apply.
- Licensed practical nurse (LPN) cleans the client's body. - Unlicensed assistive personnel (UAP) assist the client with oral feedings. - Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature.
A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include?
Salpingectomy
A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client?
before the surgery
When tasks are delegated by the registered nurse (RN) to the unlicensed nursing personnel (UNP), who can assume the responsibilities when the RN goes for a break?
charge nurse
Which among the Five Rights of Delegation is the cornerstone of delegation?
"Right communication and direction"
Which aspects are considered when determining the willingness of a nursing assistant before delegating a task? Select all that apply.
- Attitude - Confidence - Commitment
The nurse is assessing the level of readiness before delegating tasks to unlicensed assistive personnel (UAP). According to Hersey's model of situational leadership, what specific factors reflect the level of readiness? Select all that apply.
Ability, Willingness
Which action should be the nurse's first priority for a client with major burns?
Assessing airway patency
What is the priority nursing action for a scorpion bite?
Assessing the client's vital signs
The nurse manager noticed that one of the staff nurses is giving excuses for performing one task on time but ignoring another assigned task. What does the nurse manager do in this situation?
Identify the reason for procrastination.
A nurse who is assigned to care for a 6-month-old infant with diarrhea is reviewing the infant's medical history, assessment findings, laboratory reports, and practitioner prescriptions. The infant weighs 15½ lb (7 kg). The healthcare provider has written a prescription for potassium chloride to be added to the IV fluids. What assessment finding signals the nurse to question this prescription?
Urinary output of 4 mL over 2 hours
A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity?
Beneficence
What steps should a nurse take when caring for a client to prevent nursing malpractice? Select all that apply.
- Be alert about common sources of client injuries. - Gain knowledge regarding current nursing practices. - Communicate with the client regarding tests and treatment plans.
What should a nurse manager as a leader do to provide a non-threatening and positive environment to the group members?
- Encourage group members to actively participate - Create an environment conducive to solving problems - Protect the members and their suggestions from attack
A client expresses a complete lack of interest in food. How should the nurse document this finding in the client's medical record?
Anorexia
A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C). What is the priority nursing action?
Suctioning the nasopharynx so a patent airway can be maintained
A registered nurse is teaching a group of student nurses about concepts of triage in a mass casualty incident. Which statement of the student nurse indicates effective learning?
"I will issue a green tag to class III, nonurgent clients."
A large group of clients injured in a gas explosion are admitted to the emergency department. To which group of clients should treatment be provided immediately?
A group with active hemorrhaging
A nursing student is evaluating different scenarios that are examples of following the basic health care principles. Which scenario is an example of following the principle of justice?
A nurse manager encourages the nurses to discuss their mistakes in order to improve the quality of care.
After an earthquake, the emergency medical service (EMS) providers' team is performing triage functions in the field. How would the nurse describe how the EMS teams categorize the triage of clients? Select all that apply.
Clients are assigned with specific numbers Clients are provided with specific colored tags
Which individual is categorized as one who would be considered as "dependent status"?
LPN
The nurse manager is planning to delegate tasks to Unlicensed Assistive Personnel (UAPs). What care can be delegated on a medical-surgical unit to a UAP? Select all that apply.
- Performing a bed bath for a client on bed rest - Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
A nurse leader, along with the team, is caring for a client who is scheduled for colonoscopy. Which delegated task requires the leader's supervision?
Assisting the client with an enema
The nurse is caring for clients who have been admitted to the emergency department after a bomb blast. On observing one client's legs, the nurse gives the client a yellow tag. What is the likely condition of the client?
Compound fracture
How does the International Classification of Nursing Practice (ICNP) help nurses deliver effective care to clients?
It provides vocabulary to include nursing data in computerized information systems.
A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving?
Right circumstance
A primary healthcare provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do?
Schedule the client for an appointment.
Which theory emphasizes that leadership effectiveness depends on the executive nurse's interpersonal skills?
Situational-contingency theories
The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation?
The situation describes assignment.