Leader final

A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?

I have not received any of my medications today

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Monitoring vital signs of a client who had an appendectomy 12 hr ago

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate

A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom?

No one

A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

Compare the number of medication errors before and after the action was implemented

As assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first?

Gather data about the nurse's work performance and attendance history

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

Give positive feedback directly to the AP

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has a cast on the left leg and reports numbness and paresthesia

A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

A client who has a lumbosacral spinal tumor

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?

A client who has a punctured femoral artery

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?

A client who is 3 days postoperative following gastric bypass surgery

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A dependent adult admitted for the treatment of a spiral fracture

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?

A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

A young adult client who has Crohn's disease is 1 day preoperative for an ileostomy

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager?

Address the concern with the specific staff nurse

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment?

Allow time during the workday when each nurse can demonstrate proficiency

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (SATA)

Ambulate a client who has a cane o Transfer a client to a stretcher o Record urinary output

A nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict?

An experienced nurse is uncivil to a newly licensed nurse

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?

Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

Approach the man and ask why he is making copies

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?

Ask what she will be assigned to do

A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?

Assessing a client's sacrum for edema

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report?

Assessment

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?

Assigning the most efficient AP to perform glucometer monitoring for each client

A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)?

Assisting a client with crutch walking following knee replacement surgery

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?

Autonomy

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?

A client discovers that his dentures are missing

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following?

Confirms the client appears competent to provide consent

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegating?

Delegation permits a designated individual to meet a goal on your behalf

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following?

Determining the client's level of understanding about the procedure

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?

Discovery phase

A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?

Encourage the client to verbalize questions

A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights is an example of which of the following?

False imprisonment

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?

Focus on providing care that prevents life-threatening emergencies

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

I have to choose a family member as my health proxy

A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?

I need to talk to you about the unit policies regarding client assignments

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

I need to talk to you about unit expectations regarding delegating and completing tasks

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?

I should expect the hospice team to help me manage my dyspnea

A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?

Identify the problem

A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate?

If you render aid in an accident, do not leave the scene until another competent person can take over

A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take?

Initiate seizure precautions

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

Keeping an appointment with a client

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate?

Let's talk about your concerns about the new policy

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?

Nonmaleficence

A nurse on a medical-surgical unit has accepted a transfer to the intensive care unit (ICU). Prior to transfer to the ICU, the nurse contemplates an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles?

Nonmaleficence

The nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

Nonmaleficence

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?

Notify the nursing supervisor of the concerns

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

Observing a postoperative client who is confused

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

Platelet count 60,000/mm3

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

Pull the curtain around the client's bed

A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?

Quality of nursing care provided

A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?

Quietly tell the Aps that this is not appropriate

A nurse in an emergency department received report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents?

Radiologic

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?

Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?

Respite care

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Review the events leading up to each medication administration error

A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?

Set a target date

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?

State Nurse Practice Act for the LPN

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?

Submit the incident report to the risk manager

A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between he two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first?

Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately

When planning delegating of tasks to assistive personnel (AP), a nurse considers that five rights of delegation. Which of the following should the nurse consider which using one of the five rights of delegation?

The AP has the knowledge and skill to perform the task

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

The client was found unconscious on the floor in her home

A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?

The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?

The physiologic status of the clients on the unit

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information?

The purpose of medication reconciliation is to prevent adverse medication reactions

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating to the LPN?

The state Nurse Practice Act

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?

Transferring a client to the discharge location

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?

Transporting a school-age client who is in traction to another department

A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take?

Verify the LPN knows how to do a dressing change

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Wash the site of injury with soap and water

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?

Withholding a dose of narcotic pain medication when the client has respiratory depression

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (SATA)

o Obtain vital signs from a client who is 6 hr postoperative o Administer a tap-water enema to a client who is preoperative o Catheterize a client who has not voided in 8 hr

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

o Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (SATA)

o The date of the incident o The time the client was to receive the medication o The client's vital signs