EXAM 3

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?

"I have plans after work and will not be able to work overtime."

A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions?

"I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary?

"We can't discuss a client's medical condition."

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply.

- A blood test is available for the detection of anthrax. - One way that anthrax can be contracted is through the skin.

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse's new role? Select all that apply.

- Evaluating and updating the plan of care as needed - Assessing the client's needs for home supplies and equipment - Coordinating consultations and referrals to facilitate discharge - Establishing a safe and cost-effective plan of care with the client

A nurse, assessing a client's readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply.

-"I don't have any nightlights in the house." -"I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply.

-"I need to remove my wall-to-wall carpeting." -"I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. What does the nurse determine that the authority to make decisions is vested in? Select all that apply.

-A narrower span of control -A few individuals, such as the board of directors -Decision-making authority concentrated in the top level of the hierarchy

A nurse is employed in a community hospital as a nurse manager. What does the nurse understand that in this position, the term authority most appropriately refers to? Select all tha apply.

-Ability to command an action -Power of an individual to approve an action -The official power to see that an organizational decision is enforced

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply.

-Acknowledge the client's feelings -Provide information about hospital routines -Allow the client to have as many choices regarding his care as possible

According to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, what are the components of actions in the mitigation phase? Select all that apply.

-Actions that can prevent the occurrence of a disaster -Measures that can reduce a disaster's damaging effects -Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of signs/symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply.

-Change positions slowly." -"Remove clutter from your home."

A nurse is providing a change-of-shift report on his/her assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply.

-Client needs and priorities of care -Current diagnosis and any secondary diagnoses -Results of laboratory studies conducted that day -Client response to treatments implemented that day

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. This client has a tendency to be forgetful. Which items in the home increase the client's risk for injury? Select all that apply.

-Cooking equipment such as a stove -Common household objects such as door mats

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply.

-Define professional practice -Describe an acceptable level of client care -Are authoritative statements that describe a common level of performance

A nurse is attending an in-service program on disaster preparedness. Which of the following events are described as examples of natural disasters? Select all that apply.

-Flood -Drought -Hurricane

A physician writes a prescription for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply.

-Frequently assessing the client's skin for signs of burns -Assessing the client's medical history and risk factors for burns -Assessing the heating pad periodically for proper electrical function

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply.

-Have a first aid kit available. -Plan a meeting place for family members. -Have an adequate supply of prescription medications. -Have a battery-operated radio and a flashlight and batteries available.

Which of the following statements reflect the principles of sterile technique? Select all that apply.

-If a package is not labeled as sterile, it should be considered unsterile. -Sterile objects that come in contact with unsterile objects are to be considered contaminated. -Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

A new nurse employed at a community hospital is reading the organization's mission statement. What statements suggest that the new nurse understands what the organization's mission is? Select all that apply.

-Incorporates statements of philosophy (beliefs) -Outlines what the organization plans to accomplish -Includes the organization's purpose,goals or objectives

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? Select all that apply.

-Inhalation -Direct contact -handling of contaminated materials

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply.

-Italian bread -Baked chicken -Well-cooked cheeseburger

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply.

-Keeping bedside table surfaces clean and dry -Changing dressings that become wet or soiled -Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin -Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

In which situation is the nurse upholding the ethical principle of fidelity? Select all that apply.

-Keeping promises made to clients. -Contacting the primary health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3 (0.5 x 109/L). Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply.

-Monitoring the client's oral temperature -Maintaining sterile occlusion of intravenous (IV) catheters -Performing meticulous skin decontamination before venipuncture

The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply.

-Pharyngeal diphtheria -Streptococcal pharyngitis -Meningococcal pneumonia

A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply.

-Positioning the sterile field so that it remains in full view -Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand

A nurse is planning care for her assigned clients. What does the nurse know about the purpose of the hospital's standards of care? Select all that apply.

-Provide direction for the practice of nursing -Provide competent care on the basis of current practice

A client with paraplegia has spasticity of the leg muscles. Which nursing interventions should be included in the plan of care for this client? Select all that apply.

-Range-of-motion exercises of the affected limbs -An as-needed prescription for a muscle relaxant -Removal of potentially harmful objects near the client -The use of padding against the client's legs when the client is sitting in a wheelchair

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply.

-Respiratory (Lungs) -Gastrointestinal -Integumentary System (Skin)

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply.

-Saving vomitus for laboratory analysis -Determining the type and amount of substance ingested -Removing any visible materials from the nose and mouth -Assessing the client's airway patency, breathing, and circulation

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. What does the nurse know that a DNR order means? Select all that apply.

-That it must be legally and ethically implemented. -The DNR order may be changed once it is in effect -The DNR order requires frequent review as specified by state or agency policy -The client is the responsible person who may change the DNR order.

A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply.

-The assistant positions a box that is to be lifted between his knees. -The assistant keeps the object to be moved as close to his body as possible.

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply.

-The client becomes agitated. -The skin under the restraint is red. -The client's left hand is pale and cold. -he client slips his hand from its restraint and pulls at his gastrostomy tube.

After discussing the use of restraints with a client and family, the primary health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply.

-The restraints are being released every 2 hours. -A safety knot has been used to secure the restraints. -The call light has been placed within reach of the client.

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, what is the priority action by the nurse?

Administer cardiopulmonary resuscitation (CPR)

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin?

An itchy bump

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant?

An unconscious client who requires oral care

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. What is the most appropriate action the nurse can take?

Ask the nurse manager of the intensive care unit (ICU) to discuss the assignment

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?

Ask the nurse whether he/she intends to report the error

A nurse is assisting a primary health care provider in assessing a hospitalized client. During the assessment, the primary health care provider is paged to report to the recovery room. The primary health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?

Asking the primary health care provider to write the prescription in the client's record before leaving the nursing unit

A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. What is the most appropriate action by the RN?

Asks the LPN to complete and file an incident report

A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet?

Avoid sharing towels or other items that have come in contact with the vaccination site.

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, what would be the first activity that the nurse would suggest to the task force?

Conducting a community survey to assess community perceptions regarding school violence

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to deal with the conflict?

Confront the LPN and encouraging him/her to express his/her feelings regarding the change

A primary health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the primary health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

Contact the nursing supervisor

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. The nurse suspects early acute compartment syndrome. On the basis of these assessment findings, which action should the nurse take first?

Contact the primary health care provider

The nurse notes that a primary health care provider has documented the following prescription in a client's record: Furosemide 40 mg stat once. What action should the nurse take?

Contact the primary health care provider

A primary health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client with what types of power?

Expert power

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. What is the best action by the nurse conducting the program?

Explain to the television crew that videotaping is not allowed

The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the primary health care provider. The primary health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first?

Inform the primary health care provider that removal of a chest tube is not a nursing procedure

What is an example of the nurse using surgical asepsis?

Maintaining objects and areas free from pathogenic microorganisms

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first?

Peripheral pulses

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request?

Remove a restraint from one extremity

A nurse employed in a physician's office hears a client in the waiting room call out, "Help! Fire!" The nurse rushes to the waiting room and finds that the wastebasket is on fire. What should the nurse immediately do?

Remove the clients from the waiting room

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first?

Submerge the end of the chest tube in a bottle of sterile water

A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's vital signs, completes an incident report, and calls the primary health care provider to report the error. The primary health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take?

Tell the primary health care provider that the error warrants the completion of an incident report

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

The client's intake was 360 mL

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care?

Wearing gloves when emptying the client's bedpan

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. What does the nurse instruct the client to do?

Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first?Client Medications 1. Atorvastatin 10 mg orally 2. Zolpidem 5 mg orally daily 3. Ferrous sulfate 1 tablet orally 4. Levothyroxine 137 mg orally

4

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse?

"Antibiotic therapy is usually prescribed and will cure the infection."

The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be?

"Has the disaster plan been activated?"

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls?

"I took the bathmat out of my tub."

The nurse enters a client's room to administer a medication that has been prescribed by the primary health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

"It's called furosemide, and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching?

"My boyfriend doesn't have to come in for treatment."

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she/he understands how a care map is used. Which response indicates understanding?

"The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge."

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client understands the directions? Select all that apply.

- "I need to follow the oxygen prescription exactly." -"I have to keep the oxygen concentrator out of direct sunlight." -"I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator."

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply.

-"You are responsible for your own actions." -"It carries legal implications for task performance." -"It refers to the process of answering or being responsible for what occurs."

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply.

-Conduct client rounds before taking the break -Take the break in the staff lounge located on the nursing unit

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? Select all that apply.

-Providing disaster relief -Identifying and training personnel for disaster response -Educating the public about ways to prepare for disasters

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply.

-Skin integrity of the restrained body part -The procedure used in applying the restraint -The date and time of application of the restraint -Circulatory and neurovascular status of the restrained extremities

An older client in a long-term care facility is at risk for injury because of confusion. Which of the following devices would be the best choice to help prevent injury while the client is in bed?

-bed alarm

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN?

A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

A nurse working the 7 am-to-3 pm shift is reviewing the records of him/her assigned clients. Which client should the nurse assess first?

A client scheduled for hemodialysis at 10 am

A nurse is assigned to care for four clients. Which client should the nurse assess first?

A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first?

Activate the agency disaster plan

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first?

Activating the fire alarm

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. What action by the LPN helps the RN to determine that the LPN is performing the procedure correctly?

Administers the injection 2 inches (5 cm) below the acromion process

A nurse in a post-anesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first?

Airway patency

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive?

Ambularm

The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

Ask the client for permission to lock the necklace in the hospital safe

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant?

Assisting a client with dysphagia in eating

The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. What should the nurse instruct the mother to do immediately?

Call a poison control center

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted?

Close intimate contact

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the most appropriate way for the nurse manager to deal with this situation?

Confronting the nurse to discuss the behavior and initiate problem-solving measures

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. What would be the most appropriate action by the nurse?

Contact the primary health care provider

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home?

Disposing of contaminated tissues in a container with a leak-proof bag

A client with diabetes mellitus is being seen in the outpatient clinic. The client takes a daily dose of NPH insulin and is having a hard time drawing the insulin into a syringe because of difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral?

Home care

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?

Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

Oxygenating the client with 100% oxygen

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate?

Placing a surgical mask on the client for transport and for contact with other individuals

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care?

Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A home health nurse is performing an assessment of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client?

Putting on a gown and gloves

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

Realigning the client

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem?

Reminding the employee of the employment standards of the agency

The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take?

Report the incident to the nursing supervisor

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

She will have to discuss the prescribed test with the client.

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. What observed activity by the nursing assistant would lead the RN to conclude that the nursing assistant is performing the procedure incorrectly?

Stands behind the client

A primary health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The primary health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond?

Telling the primary health care provider that "slow codes" are not acceptable

A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client?

That anatomical gifts should be made in writing and signed by the client

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment?

The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home.

During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary?

The nursing assistant keeps his/her knees straight and his/her feet close together.

Which event would require a nurse to complete and file an incident report?

When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse?

"A space heater can be used as long as it's placed at least 3 feet (1 meter) from anything that may ignite."

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply.

-A client with a colostomy who requires reinforcement regarding the procedure for irrigation -A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. What does the nurse interpret the meaning of this infection? Select all that apply.

-A nosocomial infection -A healthcare-associated infection -A hospital-acquired infection

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply.

-A victim with a limb amputation -A victim who is dazed and staggering around the other victims

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply.

-A victim with respiratory distress -A victim with partial amputation of the foot

A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client's room and tells the nurse that a primary health care provider has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse?

-Asking the nursing assistant to obtain a telephone number from the primary health care provider so that the nurse may return the call after the wound irrigation is complete

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply.

-Assess the client's visual acuity -Observe the client's gait and posture -Evaluate the client's muscle strength -Look for any hazards in the home environment

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. What are the reasons for the nurse to review the chart? Select all that apply.

-Be familiar with the organization's line of authority -Be knowledgeable of how communication channels are established -Understand the way an organization depicts how activities are arranged

A nurse is preparing a sterile field to change a client's sterile dressing. What are some sterile techniques the nurse must adhere to? Select all that apply.

-Do not turn your back to the sterile field at any time. -Maintain the sterile field and gloved hands above the level of the waist.

A community health nurse is asked to assist in developing a community disaster plan identified by Federal Emergency Management Agency (FEMA). The nurse knows that the preparedness phase of the plan includes what components? Select all that apply.

-Evacuation -Planning for rescue -Caring for disaster victims -Training of disaster personnel

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply.

-Gown -Gloves -Face shield

Which of the following actions are in keeping with the principles of standard precautions? Select all that apply.

-Handwashing between client contacts -Discarding needles in puncture-resistant containers -Wearing a face shield as a part of the protective garb during a wound irrigation -Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precautions does the nurse understand are most appropriate to help ensure the safety of this client? Select all that apply.

-Switching injection sites -Applying prolonged pressure to the sites of the IM and SC injections

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L), notifies the primary health care provider, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply.

-The primary health care provider was contacted. -The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). -n IV solution of 5% dextrose in water was infusing at 7 am.

A nurse educator is providing in-service sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply.

-The use of shielded needles -The use of recessed needles -The use of needleless devices -Disposal of needles in special puncture-resistant containers

n which of the following situations would the nurse use this type of restraint (mits)? Select all that apply.

-To prevent dislodgment of an intravenous line -To prevent the use of the hands while allowing free arm movement

A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply.

-Transmission of hot impulses is delayed. -The client's peripheral vision is decreased. -The client complains of frequent nocturia. -Voluntary and autonomic reflexes are slowed.

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply.

-Untacked rugs on the stairs -Small rugs in the living room -Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply.

-Using tongs to collect any broken glass -Wearing gloves for the cleanup procedure -Disinfecting the area of the blood spill with a dilute bleach solution

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply.

-Wear a lead shield when in the client's room. -Wear a dosimeter film badge when in the client's room. -Keep all bed linens and dressings in the client's room until the implant is removed.

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up?

A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy.

A community health nurse is providing an educational session on childhood poisoning at a local school. What does the nurse tell the group what the first action is when an accidental poisoning occurs?

Call the poison control center

The nurse calls a primary health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The primary health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide but does not specify the route of administration. What is the appropriate action on the part of the nurse?

Call the primary health care provider who gave the telephone prescription to clarify the prescription

A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10-car wreck on the interstate will be brought to the ED. How does the nurse manager initially manage this situation?

Calling the nursing supervisor to discuss activation of the disaster plan

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by taking which action?

Calling the surgeon and asking that the risks be explained to the client

The nurse and an assistive personnel (AP) enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

Check the client's level of consciousness and vital signs

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. What should the nurse do first before administering the medication?

Check the placement of the tube

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. What should the nurse do to determine the necessary actions in regard to this client's injury?

Check the unit policy for the protocol for the care of clients who have been sexually assaulted

A nurse manager arrives at work and is immediately faced with several activities that require attention. Which activity will the nurse manager attend to first?

Client assignments for the day

The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?

Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

A nurse is reading the nurse practice act for the state in which he/she is employed. How does the nurse use the information in this act?

Be aware of the role of the professional nurse

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety?

Belt

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that he/she will not work the overtime if he/she has made other plans after his/her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict?

Confronting the nurse regarding his/her behavior regarding the overtime policy

The charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriate action for the charge nurse to take?

Contact the nursing supervisor

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

Contacting the surgeon and requesting that he/she visit the client to answer her questions

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client?

Keeping the door to the client's room closed

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention?

Tertiary

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital primary health care provider that the client has no other family members and that his wife is mentally incompetent. The client's primary health care provider writes a DNR order. What knowledge by the registered nurse indicates a need for further education?

That everything possible must be done if the client stops breathing.

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. What is the most appropriate action by the nurse?

The DNR request should be discussed with the physician, who will write the order

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure?

The assistant applies the restraint so that the strap does not tighten when force is applied against it.

A home health nurse has been called to the home of an older postoperative cardiovascular client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of this client's falling out of bed?

The caregiver leaves both side rails down while the client is in bed.

The nurse calls a primary health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The primary health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?

The primary health care provider was called to clarify the prescription for morphine sulfate

Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. What does the nurse, providing instructions to a nursing assistant about caring for the client, tell the assistant?

To wear gloves and a gown when changing the client's bed linen.

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act?

Using clean gloves to change a gastrostomy tube dressing

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action?

Verifying the primary health care provider's prescription

A nurse giving a client a bed bath drops the towel on the floor. What should the nurse do?

Wash his/her hands and go to the linen room to obtain another towel

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion?

Wearing gloves, a mask, and eye protection

ID: 20309110297 A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention?

Wiring for the television runs under the carpet.

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (assistive personnel)? Select all that apply.

-A client who requires transport to the radiology department in a wheelchair -A client with a Foley catheter for whom a 24-hour urine collection is in progress

A case manager is reviewing progress notes in a client's medical record. Which notation indicates the need for follow-up? -Client 1 Status post-mastectomy:18 hoursFive milliliters of bloody drainage was emptied from the Jackson-Pratt drain. -Client 2Heart FailureCrackles were heard in the lower lung lobes bilaterally on auscultation. -Client 3Status post-appendectomy: 24 hoursThe surgical dressing is clean and dry. -Client 4Diabetes mellitus Blood glucose level is 124 mg/dL (6.9 mmol/L).

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A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will he/she plan to care for first?

A client who is scheduled for surgery at 1 pm

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant?

A client who needs frequent ambulation with a walker

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply.

A client with a central venous catheter has a temperature of 100.6° F (38.1°C).

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member?

A client with a solid sealed cervical radiation implant

A nurse is planning the client assignments for the shift. Which client is most appropriate for the nurse to assign to the nursing assistant?

A client with diarrhea on whom contact precautions have been imposed

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (assistive personnel)?

A client with renal calculi whose urine must be strained

A nurse manager tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. What does the nurse manager say is a primary component of disaster readiness?

Describe a formal plan of action for the coordination of a response

A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What is the most appropriate action the nurse should do?

Determine the need for the appliances now plugged into the needed wall socket

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. What is the most appropriate initial action for the nurse to take?

Determining the appropriateness of the planned health activity

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take?

Discard the package

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." What is the most appropriate way the nurse leader would manage this issue?

Discourage the judgmental comments

A primary health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the primary health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

Discussing the situation with the nurse manager

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. What action by the new nursing graduate suggests to the nurse that the new nursing graduate needs assistance with time management?

Documents task completion and client information at the end of the day

Which action exemplifies the use of evidence-based practice in the delivery of client care?

Donning sterile gloves to change an abdominal wound dressing

A client receives cefazolin sodium by way of the intravenous route. During the infusion, the client begins exhibiting signs/symptoms of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. What does the nurse most accurately document?

During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The primary health care provider was notified.

A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. How often does the nurse instruct the nursing assistant to release the restraints to permit muscle exercises?

Every 2 hours

The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take?

Explain to the client why the wedding band must be removed

A nurse educator is providing an in-service program to emergency department nurses about the signs/symptoms of inhalation anthrax. What does the nurse educator tell the nurses is an early indication of inhalation anthrax?

Flulike signs/symptoms

A nurse has delegated several nursing tasks to staff members. What is the nurse's primary responsibility after delegation of these tasks?

Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

A nurse manager discusses staff empowerment with the nursing team. What does the nurse manager tell the staff what empowerment means?

Fosters the growth of others so that they are less dependent on the leader

A registered nurse(RN)is watching as a new licensed practical nurse(LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely?

Gloves, gown, and face shield

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?

Nonmaleficence

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis?

Obtain new IV tubing

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

Occupational therapy

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate?

Telling the nursing student to allow the client to rest

The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. What does the nurse do first when demonstrating appropriate use of the fire extinguisher?

Pulling the pin on the fire extinguisher

A nurse is admitting a postoperative client from the post-anesthesia care unit (PACU)to the surgical nursing unit. Which of the following measures should the nurse take for the safety of the client?

Putting the side rails up after moving the client from the stretcher

The nurse administers a dose of ramipril 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the primary health care provider and nursing supervisor of the error. What statement does the nurse add to the client's record?

Ramipril 2.5 mg was administered at 9 am.

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first?

Respiratory status

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation?

Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had his/her technique validated

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, what does the nurse tell the client?

She will need to sign an informed consent form

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's primary health care provider does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is best?

Staying with the client and consulting with the nurse manager about the situation

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right?

Telling the client that he or she may not leave the hospital

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is most important?

The names of close friends and family members

Which action by the nurse represents the ethical principle of beneficence?

The nurse administers an immunization to a child even though it may cause discomfort.

The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which statement accurately describes the nurse's response to the client?

The nurse could be charged with assault.

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. What does the nurse do in regard to informed consent for the surgery?

The nurse understands that consent is not needed

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching?

The nursing student washes her hands before glove removal after emptying a Foley bag.