Leadership 4

53. A nurse on a medical- surgical unit is caring for a client who asks about advance directives and states the he wants to appoint a health care proxy. Which of the following responses should the nurse make? o " It is necessary for an attorney to approve your health care proxy" o " A health care proxy can make decisions for you when you are unable to do so" o " You must choose a member of your family to serve as your health care proxy" o " You should appoint a health care proxy before undergoing an invasive procedure"

o " A health care proxy can make decisions for you when you are unable to do so"

65. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o " A provider can write a prescription for restraints 'as needed' o " I should tie the restraints using a square knot" o " I need to tie the restraint to the part of the bed frame that moves" o " I will remove the client's restraints every 4 hours"

o " I will remove the client's restraints every 4 hours"

47. A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. Which of the following responses should the charge nurse make? o " We should discuss your concerns with the client's care team" o " I will need to notify the client's provider about the breach of confidentiality" o " Please stop discussing the client in a public area" o " Do you understand HIPAA regulations?"

o " Please stop discussing the client in a public area"

27. A nurse reports to a charge nurse that a client's visitor slipped and fell. The visitor denies any injury and is walking around. Which of the following instructions should the charge nurse give the nurse? o " Have the visitor sign a waiver" o " Document the incident report in the client's medical record" o "Offer the visitor an analgesic" o " Record the event on an occurrence report"

o " Record the event on an occurrence report"

7. A nurse is providing a change of shift report for the oncoming nurse. Which of the following information should the nurse include in the report? o " The client's partner came to visit him 2 hours ago and smelled of alcohol." o " The client is the president of a local bank." o " The client will need vital signs checked every 4 hours." o " The client is currently in the radiology department for a chest x-ray."

o " The client is currently in the radiology department for a chest x-ray."

55. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? o "A nurse can apply restraints on a PRN basis" o "A nurse can administer medications without consent to a client as part of a research study" Patients have right to refuse o "A nurse can disclose information to a family member with the client's permission." o "A nurse is responsible for informing clients about treatment options"

o "A nurse can disclose information to a family member with the client's permission."

60. A nurse is planning care for four clients who were classified using a disaster triage tag team system following a mass casualty event. Which of the following clients should the nurse identify as priority? o A client who has a red tag o A client who has a yellow tag (delayed - serious but not life threatening) o A client who has a green tag (minor, walking wounded) o A client who has a black tag

o A client who has a red tag

23. A nurse is caring for a group of clients. Which of the following clients should the nurse see first? o A client who is postoperative and has a fever (nonurgent) o A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to10 o A client who has pressure ulcer has serosanguineous drainage on the dressing o A client who has diabetes mellitus and is diaphoretic

o A client who has diabetes mellitus and is diaphoretic

39. A nurse is working with a licensed practical nurse (LPN) to care for a group of clients. Which of the following clients should the nurse delegate to the LPN? o A client who has leukemia and requires an updated plan of care o A client who is transferring from the PACU following abdominal hernia repair o A client who has type 1 diabetes mellitus and receives insulin before meals o A client who requires discharge teaching about a newly described medication

o A client who has type 1 diabetes mellitus and receives insulin before meals

66. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse care for first? o A client has pneumonia and requires a tracheostomy dressing change o A client has a new colostomy and requires discharge teaching o A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea o A client who is 4 hours postoperative following a hernia repair and has pitting edema of the right leg - (Compartment syndrome)

o A client who is 4 hours postoperative following a hernia repair and has pitting edema of the right leg

17. A nurse is prioritizing care after receiving report on four clients. Which of the following clients should the nurse assess first? o A client who reports feeling lightheaded when he stands up from a lying position o A client who reports an urge to void but has not urinated during the shift prior o A client who reports indigestion and pain in her jaw o A client who reports a headache with sensitivity to light

o A client who reports indigestion and pain in her jaw

28. A nurse is preparing an education program about professional codes of ethics for nurses. Which of the following information should the nurse plan to include? o A code of ethics is a step-by-step approach to decision making o A code of ethics is legally binding o A code of ethics outlines the nurses scope of practice o A code of ethics is a set of principles for nursing practice

o A code of ethics outlines the nurses scope of practice

26. A home health nurse finds piles of newspaper in the hallway of a client's home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? o Compromising o Smoothing o Collaborating o Accommodating

o Collaborating

41. A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice? o A nurse raises all four side rails on the bed of a client who is confused o A nurse refuses to care for a client who has had an abortion o A nurse withholds nutrition from a client who has DNR order - don't do this... o A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. support

o A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. support

52. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk of falls? (SATA) o A throw rug covering some cracked vinyl flooring in the kitchen o A folding chair without arm rests o A two- wheeled walker used to assist the client with ambulation o A raised vinyl seat on the toilet in the client's bathroom o A wheeled office chair at the client's computer desk

o A throw rug covering some cracked vinyl flooring in the kitchen o A folding chair without arm rests o A wheeled office chair at the client's computer desk

20. A nurse is using the SBAR communication tool while giving report on a client. The nurse should include the client's pain level after receiving a PRN dose of morphine 1 hr ago during which part of the report? o A-assessment o B-background o R-recommendation o S-situation

o A-assessment

36. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? o An adult client who has moderate Alzheimer's disease o An older adult client who has questions about the procedure o An adult client who has alcohol intoxication o An adolescent client who is legally emancipated

o An adolescent client who is legally emancipated

38. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? o A young adult client who is participating in a medical research study o An older adult client who has advance directives on file o An adolescent client whose parents refuse a blood transfusion for religious reasons o A middle adult client who leaves the facility against medical advice

o An adolescent client whose parents refuse a blood transfusion for religious reasons

32. A nurse in an emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? o An adolescent who has an injured ankle and reports a pain level of 8 on a scale of 0-10 o A toddler who has a 2cm (0.79 in) head laceration oozing dark red blood o An older adult client who has dyspnea and a respiratory rate of 26min o An adult client who has large ecchymoses on both legs

o An older adult client who has dyspnea and a respiratory rate of 26min

61. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? o File an incident report o Ask the client about his injuries with the son present o Treat and discharge the client o Ask the client's son to wait in the waiting room

o Ask the client's son to wait in the waiting room

13. A nurse is caring for a client who has signed consent for the removal of the tumor in the left frontal lobe of the brain. The client states, "The tumor is on the right side of my head." Which of the following actions should the nurse take? o Continue with the surgery because the client already gave informed consent. o Ask the surgeon to clarify the operative site with the client o Contact the surgery department to validate the operative site o Tell the client to mark the right side of his head with indelible ink

o Ask the surgeon to clarify the operative site with the client

64. A nurse is caring for a client who is scheduled for placement of central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process? o Discuss alternative treatment options with the client o Place a photocopy of the signed informed consent in the client's medical record - o Assess the client's understanding after the provider has talked to her o Review the risks and benefits of the procedure with the client

o Assess the client's understanding after the provider has talked to her

57. A charge nurse is admitting a client who speaks a different language than the nurse and will require and interpreter. Which of the following actions should the nurse plan to take? o Limit interpreter services to daytime hours o Repeat the same words to the interpreter if the client does not understand o Assign a bilingual staff member to be the interpreter when caring for the client o Pause in the middle of the sentence when using an interpreter

o Assign a bilingual staff member to be the interpreter when caring for the client

43. A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? o Notify the provider o Place a faulty equipment tag on the pump o Auscultate the client's lungs o Complete and incident report

o Auscultate the client's lungs

21. A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using? o Benchmarking o Structure audit o Risk benefit analysis o Root cause analysis

o Benchmarking

51. A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate? o Elevating the head of the bed 20 degree angle o Check residual volume before each feeding o Flushing The tube with 15 mL of water o Adding colored food dye to the formula

o Check residual volume before each feeding

2. A nurse at a local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? o Chlamydia trachomatis o Pediculosis capitis o Impetigo contagiosa o Candida albicans

o Chlamydia trachomatis

9. A nurse is preparing a shift assignment for an assistive personnel on the unit. Which of the following tasks should the nurse assign to the AP? o Check a client's pain level 30 min after receiving acetaminophen o Administer the initial bolus feeding to a client who has an NG tube o Collect a urine specimen from a newly admitted client o Instruct a client to splint an abdominal incision

o Collect a urine specimen from a newly admitted client

56. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? o Assign clients who are not prescribed narcotics to the staff nurse o Counsel the staff nurse about substance abuse use o Collect data about the staff nurse to support further action o Report the staff nurse to the facility ethics committee

o Collect data about the staff nurse to support further action -Always assess first

48. A nurse is caring for a client who reports taking a new herbal supplement after reading about it on the Internet. Which of the following instructions should the nurse provide the client? o Compare website's information with a variety of sources o Look for medical information on network (. Net) websites o Ensure the website is sponsored by a pharmaceutical company o Consider the Internet information reliable if it is written by a doctor

o Consider the Internet information reliable if it is written by a doctor

18. A charge nurse is directing the unit nurses to implement the emergency response plan for a fire on the unit. Which of the following instructions should the charge nurse give to the unit nurses? o Ask ambulatory clients to help move clients in wheelchairs to safety o Continue therapy for clients who are receiving oxygen o Close the doors of the unit before moving clients to a safe place o Maintain mechanical ventilation for clients who are on life support.

o Continue therapy for clients who are receiving oxygen

70. A nurse is assessing a client who has meningitis. Which of the following finding should the nurse report to the provider immediately? o Increased temperature o Report of photophobia o Decreased level of consciousness o Generalized rash over trunk

o Decreased level of consciousness

6. A nurse is working with a committee that is performing an annual review of policies and procedures. After gathering data, identify the sequence the committee should follow when using the stages of change. (put in order) o Determine goals 1 o Create a revised protocol 2 o Implement the revised protocol 3 o Review the results of the provisions. 4

o Determine goals 1 o Create a revised protocol 2 o Implement the revised protocol 3 o Review the results of the provisions. 4

10. A nurse is teaching a class of newly licensed nurses about evidence- based practice. The nurse should include which of the following as a first step in evidence-based practice. o Collect evidence from a variety of sources o Develop a clinical question o Apply research to client care practice o Critically assess the evidence

o Develop a clinical question

44. A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation? o Document in the incident report, ' Entered room and discovered client lying prone on the floor' o Document in the nurses report, 'Photocopy of incident report sent to risk management' o Document in incident report, 'Client found lying on the floor after falling out of bed' o Document in nurses notes, 'Incident report completed and filed'

o Document in incident report, 'Client found lying on the floor after falling out of bed'

62. A charge nurse is reviewing the actions by a nurse following a client fall. Which of the following actions by the nurse requires intervention by the charge nurse? o Lists names of witnesses to the fall in the incident report o Documents in the client's record, "Incident report was filed" o Sends the incident report to risk management o Includes the client's account of the fall in the incident report

o Documents in the client's record, "Incident report was filed"

14. A nurse is preparing to witness a client's signature on an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? o Ensuring the client appears competent to consent to the procedure o Discussing options for the alternative therapies with the client o Providing the client with a complete description of the procedure o Explaining the risks associated with the procedure to the client

o Ensuring the client appears competent to consent to the procedure

15. A charge nurse witnesses two nurses having a loud discussion at the nurses' station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? o Make arrangements to take over the clients care. o Contact the house supervisor to mediate the conflict o Escort the nurses to the nurses lounge to continue the discussion o Recommend that both nurses are terminated

o Escort the nurses to the nurses lounge to continue the discussion

30. A nurse manager discovers there is a conflict between nurses working day shift and working night shift. Which of the following actions should the nurse take? o Gather information regarding the situation o Acknowledge the conflict and encourage the nurses to focus on working as a team o Encourage the nurses to resolve the conflict autonomously o Meet with the a committee of nurses from each shift to discuss issues related to the conflict

o Gather information regarding the situation

3. A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department. o Candidiasis o Gonorrhea o Trichomoniasis o Human papillomavirus

o Gonorrhea

4. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? o Review with the nurse principles of medication administration. o Ask the nurse to describe the medication administration procedure. o Identify education opportunities for the nurse regarding safe medication administration. o Notify the risk management department of the situation.

o Identify education opportunities for the nurse regarding safe medication administration.

1. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? o Establish measurement criteria for infant safety systems. o Evaluate the selected infant safety system. o Choose an infant safety system. o Identify the industry standards for infant safety.

o Identify the industry standards for infant safety.

40. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of MRSA. Which of the following members of the interprofessional team should the nurse consult? o Infection control nurse o Nursing supervisor o Risk management coordinator o Clinical pharmacist

o Infection control nurse

46. A nurse is providing discharge teaching to a client following total knee arthroplasty. Which of the following information should the nurse include? (SATA) o Information about follow up care o Medication guideline information o Advance directives information o Contact information for the physical therapist o Insurance information

o Information about follow up care o Contact information for the physical therapist o Insurance information not sure (o Medication guideline information)

34. A nurse in a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include? o Accompany residents older than 85 years of age during ambulation o Institute rounds every 2 hr during the day to offer toileting o Keep the four side rails up on beds at night o Apply vest restraints on residents who are confused

o Institute rounds every 2 hr during the day to offer toileting

68. A nurse is providing information to a client about advance directives. The nurse should explain that advance directions include which of the following? o Instructions regarding treatments the client desires or does not desire o Information regarding organ donation o Information regarding the disposition of the client's body upon death o A form with directions for contacting next of kin

o Instructions regarding treatments the client desires or does not desire

24. A nurse manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as an HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? o Negligence o Battery o Libel o Slander

o Libel

29. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? o Rotavirus o Rubeola o Varicella o Mumps

o Mumps

49. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? o Veracity - nurse's duty to tell the truth o Nonmaleficence o Utility o Autonomy - the ability of the client to make personal decisions

o Nonmaleficence nurse's obligation to avoid causing harm to the client

69. A nurse is reviewing medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse make first? o Inform the nursing supervisor o Notify the provider o Complete an incident report o Observe the client's condition

o Observe the client's condition

50. A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take? o Tell the client to leave her purse in a drawer of the bedside table o Place the purse in the clothing bag with the clients belongings o Offer to place the purse in the facility's safe o Offer to store the purse in the nurses station

o Offer to place the purse in the facility's safe

33. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? o Pharmacist o Occupational therapist o Respiratory therapist o Physical therapist

o Physical therapist

16. A nurse is observing an assistive personnel (LPN I think) administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP(LPN I think) should the nurse intervene? o Inserts the tubing 8 cm (3.1 in) into the rectum o Positions the client on her left side with knees flexed o Points tubing in the direction of the umbilicus during insertion o Administers the solution at room temperature

o Positions the client on her left side with knees flexed Rationale: Prepare and warm the enema solution. Position the client on the left side with the right leg flexed forward. Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in).

63. A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel? o Pouching a client's established ostomy o Reinforcing teaching with a client about low-sodium diet o Demonstrating the use of an incentive spirometer to a client o Updating a family member about a client's condition

o Pouching a client's established ostomy

12. A nurse who is caring for a group of clients, delegates collection of vital signs to an assistive personnel. Which of the following actions should the nurse take to evaluate the delegated task? o Recheck vital signs that are outside the expected reference range o Review the vital sign trends at the end of the shift. o Ask the AP to write a summary of the delegated tasks during the shift. o Compare the vital signs the AP obtained with those taken by another AP on a previous shift.

o Recheck vital signs that are outside the expected reference range

42. A nurse is conducting an in service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? o Evaluating a client's home for safety hazards o Recommending a referral for a client who requires physical therapy o Completing an incident report following a medication error o Suggesting a client's partner attend a support group for emotional

o Recommending a referral for a client who requires physical therapy

58. A nurse is caring for a client who has Addison's disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel(CNA I think)? REPEAT QUESTION o Explain to the client about a 24hr urine specimen collection RN o Determine the client's muscle strength prior to ambulation RN o Decide how often to measure vital signs RN o Remind the client to change positions slowly within AP scope

o Remind the client to change positions slowly within AP scope

22. A nurse is planning a discharge for a client who has a new diagnosis of COPD and lives alone. Which of the following actions is the nurse's priority? o Provide printed materials for new prescriptions o Set up appointments in in-home physical therapy o Request a referral for a home safety assessment o Suggest participating in a community group

o Request a referral for a home safety assessment

8. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? o Child protective services o Pharmacist o Social worker o Respiratory therapist

o Social worker

59. A nurse is caring for a client who had a stroke and is experiencing difficulty swallowing. The nurse should arrange a referral to which of the following members of the interprofessional team regarding the client's condition? o Speech pathologist o Occupational therapist o Physical therapist o Social worker

o Speech pathologist - Evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing

45. A nurse is planning discharge teaching for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage tracheostomy at home? (SATA) o Cotton-twill tracheostomy ties o Suction machine o Povidone - iodine swabs o Petroleum jelly lubricated gauze o Oxygen tank

o Suction machine o Oxygen tank

54. A nurse is preparing to transfer a client to the radiology department using the wheelchair. Which of the following actions should the nurse take? o Push the wheelchair into the elevator, large wheels last/ o Leave a transfer belt in place until the client returns from radiology o Keep the footplates lowered throughout the transfer process. o Test the locks on both wheels of the chair prior to transfer.

o Test the locks on both wheels of the chair prior to transfer.

37. A nurse is completing a performance evaluation for an assistive personnel. Which of the following actions by the AP requires intervention by the nurse? o The AP wears a mask when caring for a client who has varicella o The AP removes cut flowers from the room of a client who is in a protective environment o The AP closes the door of a client who is on airborne precaution o The AP uses alcohol hand antiseptic after caring for a client who has C-Diff

o The AP uses alcohol hand antiseptic after caring for a client who has C-Diff

5. The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make the health care decision? o The provider o The oldest adult child o The partner o The client

o The client

25. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for the referral? o The client has difficulty ambulating with a walker o The client requires assistance with completing oral hygiene o The client reports pain when chewing on solid foods o The client expresses desire to join a support group

o The client requires assistance with completing oral hygiene

11. A nurse is inspecting a clients IV pump prior to use. The nurse should tag and report which of the following safety hazards? o The electrical cord is taped to the floor o The IV pump is plugged into an outlet close to the bed o The IV pump has a free-flow protective device o The electric plug has two short prongs

o The electric plug has two short prongs - (Must be 3 prongs)

67. A charge nurse is receiving change of shift report. Which of the following situations should the charge nurse report address first? o Transport assistance is unavailable to take a client to occupational therapy o The emergency department nurse is waiting to give report on a new admission o A nurse on the previous shift wrote an incident report on a medication error o Two staff members have called to say there were absent

o The emergency department nurse is waiting to give report on a new admission or (o Two staff members have called to say there were absent )---probably not

31. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? o The nurse puts on a face mask o The nurse applies goggles o The nurse holds her hands above her waist o The nurse turns her back to the sterile field

o The nurse holds her hands above her waist

35. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change of shift report? o The time the client received his last dose of pain medication o The clients preferred bath time o The belief that the client has a difficult relationship with his son o The steps to follow when providing wound care

o The time the client received his last dose of pain medication

19. A nurse is providing teaching to an older adult client regarding home safety. Which of the following instructions should the nurse include in the teaching? o Cover chords with the carpet to prevent falls o Unplug humidifier before cleaning it o Change batteries in the smoke alarm every 2 years o Set the water heater to 60 degrees C (140 F)

o Unplug humidifier before cleaning it