Management A
A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. The client reports falling while trying to go to the restroom. Which of the following actions should the nurse take first? Notify the charge nurse and the client's provider. Check the client for injuries. Request help to assist the client back to bed. Complete an incident report about the client's fall.
Check the client for injuries. MY ANSWER When using the nursing process, the nurse should identify that the priority action is to collect data from the client. Therefore, the first action the nurse should take is to check the client for injuries.
A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator? The unit sets a goal to ask all clients upon admission if they have a living will. An additional 15 wall-mounted hand sanitizers are installed on the unit. A new standardized form is developed for peer reviews facility-wide. The facility-wide fall injury rate for the previous quarter is 3%.
The facility-wide fall injury rate for the previous quarter is 3%. MY ANSWER This is a valid outcome indicator because it provides statistical evidence related to quality of care.
A charge nurse is a member of the resource management team for a skilled care facility. Which of the following actions should the charge nurse implement to ensure the facility is providing cost-effective wound care for clients? Develop a spreadsheet to prepare a budget for wound care supplies
Develop a spreadsheet to prepare a budget for wound care supplies. MY ANSWER The nurse should use a spreadsheet to manage numerical data for the preparation of a budget. The use of a spreadsheet allows the nurse to analyze this data to ensure that cost-effective care is provided to clients.
A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug in the client's electrical outlet. Which of the following actions should the nurse take first? Unplug the client's bed. Pull the fire alarm closest to the area. Evacuate the client. Call the maintenance department for assistance.
Evacuate the client. MY ANSWER The greatest risk during a fire or a threat of fire is injury to the client or others. Therefore, the first action the nurse should take is to evacuate the client from the room. This action is the first step of the Rescue, Alarm, Confine, and Extinguish (RACE) protocol.
A nurse is monitoring a client who is receiving IV fluids via an infusion pump and notes the pump is malfunctioning. Which of the following actions should the nurse take? Place a tag on the IV pump. Report the malfunctioning IV pump to the risk manager. Calculate the manual IV drip rate. Call housekeeping to pick up the IV pump.
Place a tag on the IV pump. The nurse should place a tag on the malfunctioning IV pump and remove it from service to prevent injury to the client and others.
A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following members of the interprofessional health care team should the nurse consult to assist the client with glucose management? Occupational therapist Registered dietitian Pharmacist Speech therapist
Registered dietitian MY ANSWER The nurse should arrange a consult with a registered dietitian to help the client with meal and snack plans, which will ensure stable blood glucose levels.
A nurse in a long-term care facility is caring for a client who had a stroke 1 week ago. The client is experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and memory loss. Which of the following referrals is the priority for the nurse to make? Physical therapy Speech therapy Cognitive therapy Occupational therapy
Speech therapy When using the airway, breathing, circulation approach to client care, the priority referral is to the speech therapist. Difficulty swallowing indicates that this client is at risk for aspiration. Therefore, a referral for speech therapy is the priority.
A nurse is reinforcing teaching about home safety with an older adult client. Which of the following statements by the client indicates an understanding of the teaching? "I will run extension cords under area rugs." "I will place broken glass in a plastic bag for disposal." "I will paint the edge of each of my entry steps a different color." "I will keep my water heater set at 130 degrees Fahrenheit."
"I will paint the edge of each of my entry steps a different color." The client should paint the edge of each entry step a different color because this provides contrast that makes the steps easier to see, thereby decreasing the risk for falls.
A nurse in a long-term care facility is assisting with the admission of a client. The client tells the nurse, "I don't need advance directives because my partner knows my wishes." Which of the following responses should the nurse make? "You need to confirm your wishes with a lawyer." "I will discuss advance directives with your partner." "You are required by law to have advance directives." "I will provide you with written information about advance directives."
"I will provide you with written information about advance directives." MY ANSWER The nurse is required to ask the client whether they have advance directives in place. If the client does not have advance directives, the nurse should provide them with written information about advance directives.
A charge nurse in a long-term care facility is reviewing message boards in various client rooms. Which of the following information should the charge nurse request one of the nurses remove from a client's board? "Vital signs twice daily" "I&O q4h" "Laboratory test at 0600" "Hospice nurse visit at 1600"
"Hospice nurse visit at 1600" MY ANSWER The charge nurse should request removal of any information concerning the client's medical diagnosis or treatment from message boards. HIPAA specifically prohibits posting a client's private health information because this violates the client's right to confidentiality.
A nurse is reinforcing discharge teaching with a client who is 2 days postpartum. The client expresses concern about a lack of family support and limited financial resources. Which of the following responses should the nurse make? "I've seen many new parents do well with limited family support." "Has anyone discussed the financial resources available to you?" "Once you get past the postpartum period, you'll feel better about handling these challenges." "How do you feel about discussing your concerns with a social worker?"
"How do you feel about discussing your concerns with a social worker?" MY ANSWER This is a therapeutic response by the nurse because it addresses the client's concerns and provides the client with resources to help meet their specific needs. The social worker can connect the client with supportive community resources.
A nurse is assisting with the care of a client who has terminal cancer and is receiving chemotherapy. The client tells the nurse that they are only continuing treatment for their family's sake. Which of the following responses should the nurse make? "Let's talk about your reasons for continuing treatment." "You should talk to a social worker about your situation." "I'll get the chaplain to come speak with you about your thoughts and feelings." "I know you are tired of this treatment, but you are right to think of your family first."
"Let's talk about your reasons for continuing treatment." MY ANSWER This response by the nurse is therapeutic because it focuses the conversation on the key components of the message and allows the client to discuss the treatment and any concerns they are having. The nurse also validates the client's feelings and thoughts, which can help enhance trust between the nurse and the client.
A nurse is reinforcing teaching with a newly licensed nurse about the role of the nurse in informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "My signature on the consent form indicates I informed the client they can't change their mind about the procedure." "By signing the consent form, I confirm that I was present when the provider explained the procedure to the client." "My signature on the consent form indicates the client gave consent for the procedure voluntarily." "By signing the consent form, I confirm that the client's family approves of the procedure."
"My signature on the consent form indicates the client gave consent for the procedure voluntarily." MY ANSWER The nurse's signature on the consent form confirms that the client is competent to give consent, the client gave the consent voluntarily, and that the client's signature is authentic.
A charge nurse is talking with two assistive personnel (AP) who are angry about the order in which lunch breaks are scheduled on the unit. Which of the following statements by the charge nurse demonstrates the use of compromise? "You can take turns going to lunch first every other week." "Whoever has seniority should go to lunch first." "You should try to work out the lunch schedule between the two of you." "Can we discuss this tomorrow? I need some time to think about the schedule."
"You can take turns going to lunch first every other week." MY ANSWER Successful negotiation through compromise requires that each party give up something. The charge nurse should suggest an alternating lunch schedule, in which each party gives up what they want only part of the time. This use of compromise results in a win-win outcome for all parties.
A nurse in a long-term care facility is caring for a client who has heart failure and is refusing to take a new medication. Which of the following responses should the nurse make? "You need to take this medication to feel better." "Many clients take this medication for your condition." "I will come back later to give you the medication." "You have the right to refuse the medication."
"You have the right to refuse the medication." MY ANSWER The nurse should recognize the client's right to refuse the medication to support the client's autonomy. The nurse should document this in the client's medical record and notify the provider.
A nurse enters a client's room at the beginning of a shift. Which of the following findings requires intervention by the nurse? A capped bottle of sterile water that was opened 36 hr ago A urinary catheter drainage bag that is hanging on the lower portion of the bed frame A peripheral IV catheter that was inserted 2 days ago A wound dressing that requires frequent changes and is secured using Montgomery straps
A capped bottle of sterile water that was opened 36 hr ago The nurse should discard a bottle of sterile water that was opened more than 24 hr ago.
A nurse is discussing the condition of several clients with an assistive personnel (AP) prior to routine vital sign measurement. The nurse should plan to measure vital signs for which of the following clients rather than delegating this task to the AP? A client who has a history of migraine headaches and reports an aura A client who has new onset atrial fibrillation and reports lightheadedness A client who requires a Doppler ultrasound for pedal pulse measurement due to poor circulation A client who requires droplet isolation precautions for pneumonia
A client who has new onset atrial fibrillation and reports lightheadedness MY ANSWER Clients who have new onset atrial fibrillation often experience lightheadedness, tachycardia, and hypotension. Because the client's condition is unstable and might require nursing judgment, the nurse should plan to measure this client's vital signs.
A nurse is assisting with the evacuation of clients who have been triaged following a mass casualty event. Which of the following clients should the nurse recommend for first transport to the health care facility? A client who has a penetrating head wound and has been assigned a black tag A client who has a compound fracture to the left arm and has been assigned a yellow tag A client who has multiple abrasions and bruising to the trunk and has been assigned a white tag A client who has paradoxical respirations and has been assigned a red tag
A client who has paradoxical respirations and has been assigned a red tag MY ANSWER When using the airway, breathing, circulation approach to client care, the nurse should recommend transporting the client who has paradoxical respirations first. A client who has paradoxical respirations requires immediate intervention for survival, due to airway compromise.
A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation? A verbal prescription from the provider taken by the charge nurse Entry of the completion of a procedure in advance A treatment that was refused by the client Subjective findings regarding the client's pain tolerance
A treatment that was refused by the client MY ANSWER The nurse should document treatments that were omitted due to client refusal in the medical record.
A charge nurse is evaluating the documentation of care for four clients by a newly licensed nurse. Which of the following entries requires intervention by the charge nurse? Client medicated with morphine 30 mg PO for report of right shoulder pain rated 7 on a scale of 0 to 10. Administered 10.0 u of insulin SQ to client for elevated glucose level. Reinforced to client to turn, cough, and deep breathe every 2 hr while awake. Client verbalized understanding. Reported client's oral temperature 39.7° C (103.5° F) to provider.
Administered 10.0 u of insulin SQ to client for elevated glucose level. MY ANSWER This entry requires intervention by the charge nurse for the use of unapproved abbreviations (u, SQ), a trailing zero (10.0), and incomplete information including type of insulin, how it was administered, and glucose level.
A nurse on a pediatric unit is assisting with the care of a group of clients. Which of the following clients would benefit most from an interprofessional care conference? An infant who has cystic fibrosis and is continuing to lose weight An infant who has pneumonia and is receiving IV antibiotics A school-age child who has sickle cell disease and is scheduled to receive a blood transfusion A school-age child who has spina bifida and whose parent needs to learn to perform intermittent catheterization
An infant who has cystic fibrosis and is continuing to lose weight When using Maslow's hierarchy of needs, the nurse should determine that this client is the priority for an interprofessional care conference to meet the client's need for food and fluids. This client is at risk for inadequate nutrition resulting in impaired growth. Addressing this problem requires a multidisciplinary approach, including a dietitian.
A nurse is contributing to the plan of care for a client who has a prescription for a 24 hr urine specimen. Which of the following interventions should the nurse plan to include? (Select all that apply.) Begin the timed collection by discarding the first specimen. Post the times for urine collection above the toilet in the client's bathroom. Document volume estimations of missed voids. Obtain a clean specimen collection container for use during the test. Remove feces or toilet paper that is in the specimen collection container.
Begin the timed collection by discarding the first specimen is correct. The nurse should begin the timed collection when the client voids. This nurse should discard the first specimen. Post the times for urine collection above the toilet in the client's bathroom is correct. The nurse should post information about the urine collection testing, including the start and end time, in a prominent place to prevent accidental discarding of urine. Document volume estimations of missed voids is incorrect. In the event a client misses placing a void into the specimen collection container, the test must be restarted. Obtain a clean specimen collection container for use during the test is correct. The nurse should obtain a clean container for the client to use during the testing period to avoid contamination of the specimen. Remove feces or toilet paper that is in the specimen collection container is incorrect. Feces or toilet paper will contaminate the specimen. The nurse should instruct the client to defecate prior to voiding and to place toilet paper into the toilet bowl, rather than the collection container.
A nurse is assisting with the care of a client who is scheduled for surgery. Which of the following actions should the nurse take as part of the informed consent process? Obtain informed consent from the client. Confirm that the client understands the provider's teaching. Ensure that the client is aware of alternative treatment options. Verify that the client understands the risks and benefits of the procedure.
Confirm that the client understands the provider's teaching. The nurse's role is to ensure that the client understands the information provided by the provider and then witness the client's signature on the informed consent form.
A nurse is assisting with the care of a client who was admitted with deep-vein thrombosis. The client has decided to leave against medical advice. Which of the following actions should the nurse take? Complete an incident report detailing the client's desire to leave against medical advice. Explain to the client the risk involved in leaving the facility. Notify the client's next of kin. Assign an assistive personnel (AP) to provide one-to-one observation of the client.
Explain to the client the risk involved in leaving the facility. The nurse has a legal responsibility to inform the client of the potential risks involved with leaving against medical advice.
A nurse is reinforcing teaching with a newly licensed nurse about the administration of opioid pain medication. Which of the following instructions should the nurse include? Count the remaining narcotics after removing the client's medication from the locked dispenser. Place the unused portion of the client's medication in the sharps container at the nurses' station. Have a second nurse witness disposal of the unused portion of the client's medication. Report a discrepancy in the narcotic count immediately after administering the medication to the client.
Have a second nurse witness disposal of the unused portion of the client's medication. MY ANSWER The nurse should ask a second nurse to witness the disposal of any unused portion of a client's medication. The witnessing nurse should also document that they witnessed the disposal of the unused medication in the electronic medical record.
A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of the following manifestations should the nurse include? Diarrhea Ringing in the ears Headaches Irritability
Headaches The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning.
A nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse plan to take? Include the client's vital sign record in the discharge instructions. Begin discharge planning 24 hr prior to the client's scheduled discharge date. Include community resource phone numbers with the client's discharge instructions. Obtain a 3-month supply of the client's prescribed medications.
Include community resource phone numbers with the client's discharge instructions. MY ANSWER The nurse should provide the client with contact information for community resources, as well as the provider, to enhance care and provide easy access in the event of complications or questions.
A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The client has a portable wound bulb suction device and an indwelling urinary catheter. The nurse should recognize that the client's output is calculated and recorded correctly when the AP performs which of the following actions? Includes 0.9% sodium chloride used to irrigate the catheter in the calculated output. Includes emesis and wound drainage in the total recorded output. Measures the urine using the markings on the drainage bag. Documents drainage in cubic centimeters (cc) on the intake and output form.
Includes emesis and wound drainage in the total recorded output. The nurse should recognize that the AP understands the concept of calculating a client's intake and output when the AP includes emesis and wound drainage in the calculation of the client's total output.
A nurse overhears two assistive personnel (AP) discussing the details of a client's diagnosis and treatment plan in the hospital cafeteria. Which of the following actions should the nurse take? Report the situation directly to the facility's risk manager. Determine if both AP are directly involved in the client's care. Place a completed incident report in the client's medical record. Inform the AP that the conversation violates the client's confidentiality.
Inform the AP that the conversation violates the client's confidentiality. MY ANSWER The nurse should intervene immediately to stop the conversation and protect the client by informing the AP that the conversation violates the client's confidentiality.
A nurse is caring for an adolescent client who requires a blood transfusion. The client's parents will not consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take? Contact the facility chaplain to speak with the family. Reinforce teaching with the parents about why the blood transfusion is necessary. Inform the charge nurse and recommend that social services be contacted. Ask the client if they will accept the blood transfusion.
Inform the charge nurse and recommend that social services be contacted. The nurse has an obligation to act as an advocate for the client. The nurse should inform the charge nurse of the parents' decision and recommend that social services is contacted to further advocate for the client.
A nurse observes an assistive personnel (AP) taking a picture of a client who has not given consent. The nurse should identify that the AP has committed which of the following torts? Invasion of privacy Negligence Defamation of character Battery
Invasion of privacy The nurse should identify that taking a picture of a client who has not given consent is an invasion of privacy, which is a violation of the client's right to privacy. Examples of invasion of privacy include using the client's name for profit and taking pictures of the client without their consent.
A nurse has just received change-of-shift report for a group of clients. Which of the following actions should the nurse take to manage their time effectively? Complete low-priority tasks first. Keep a client to-do list for the day. Chart client tasks at the end of the shift. Focus on several client tasks at a time.
Keep a client to-do list for the day. MY ANSWER The nurse should keep a client to-do list for the day because this allows the nurse to track the completion of their tasks, which facilitates effective organization and time management.
A nurse is assisting with the discharge of a client who has a new permanent colostomy. The client expresses concern about learning to care for the appliance, affording colostomy supplies, and obtaining supplies discretely. Which of the following actions should the nurse take? (Select all that apply.) Suggest that the client join an ostomy support group. Arrange a follow-up appointment with an enterostomal therapy nurse. Provide the client with the name and number of an ostomy supply delivery service. Recommend that the client's discharge be postponed until their concerns are resolved. Request a social work referral for the client to discuss financial concerns.
MY ANSWER Suggest that the client join an ostomy support group is correct. An ostomy support group, such as those affiliated with the United Ostomy Association, can provide helpful information for clients who have a new ostomy. Arrange a follow-up appointment with an enterostomal therapy nurse is correct. The nurse should arrange a follow-up appointment with an enterostomal therapy nurse to help the client with ostomy care. Provide the client with the name and number of an ostomy supply delivery service is correct. The nurse should provide the client with initial ostomy supplies and inform the client of medical supply companies from which they can obtain future supplies or have them delivered discretely. Recommend that the client's discharge be postponed until their concerns are resolved is incorrect. Unless the client experiences complications, the nurse should work with the interprofessional discharge planning team to meet the client's needs prior to the scheduled discharge. The client might continue to experience apprehension about caring for a new appliance. However, this can be addressed by a home health nurse. In many cases, the ostomy supply company has an educator on staff to assist the client as they get more comfortable with the new appliance. Request a social work referral for the client to discuss financial concerns is correct. The nurse should request a referral to a social worker. A social worker can assist the client with identifying community resources and providing financial counseling.
A nurse is discussing delivery models of care with a group of newly licensed nurses. Which of the following should the nurse include as an example of the functional nursing model of care? One nurse is assigned to complete care for one client. A group of nurses work together to care for a group of clients. Nurses are assigned specific tasks to perform for each of the clients. Assignments are made based on client location within the unit.
Nurses are assigned specific tasks to perform for each of the clients. MY ANSWER Nurses use a functional nursing model when assigning specific tasks to staff. This approach places the focus on the task to be performed.
A nurse is assigned to care for a client who is in isolation. Which of the following actions should the nurse take to manage time effectively while caring for this client? Assign an assistive personnel (AP) to apply a medicated ointment during perineal care. Store several sets of extra bed linens in the client's room. Organize care tasks into groups that can be performed at one time. Schedule time at the end of the shift to document all client care.
Organize care tasks into groups that can be performed at one time. MY ANSWER The nurse should implement this strategy because it streamlines the workflow by providing less fragmented care and reducing the time spent traveling from area to area.
A nurse is contributing to the development of a fall prevention policy for clients who have dementia. Which of the following sources of information should the nurse identify as the primary guideline for the creation of the policy? Clinical expertise of facility nurses Review of medical records Facility performance indicators Peer-reviewed nursing journals
Peer-reviewed nursing journals The nurse should collect data from peer-reviewed journals when contributing to the development of a new policy. This is the primary guideline the nurse should use because it is current, accurate, and research-based.
A nurse is preparing to delegate assignments after receiving change-of-shift report. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Provide postmortem care. Insert a nasogastric tube. Obtain a specimen for a wound culture. Instruct a client on the use of an incentive spirometer.
Provide postmortem care. MY ANSWER The nurse should assign the AP to provide postmortem care because this task is within the AP's range of function
A nurse is contributing to the plan of care for a client who has acute hypothyroidism. Which of the following interventions should the nurse include in the plan? Provide the client with a cool environment. Provide the client with a reduced-calorie diet. Place the client on a fluid restriction. Place the client on strict bed rest.
Provide the client with a reduced-calorie diet. MY ANSWER The nurse should provide a client who has hypothyroidism with a reduced-calorie diet. Hypothyroidism causes the client's metabolism to decrease, which can result in weight gain. A reduced-calorie diet will help the client minimize weight gain and can contribute to weight loss.
A nurse on a facility's performance improvement team is assisting to develop practice guidelines for performing bladder scans. Which of the following actions should the nurse take prior to developing a policy and procedure for this task? Review evidence-based practice data related to bladder scanner use. Compare the cost of indwelling urinary catheters with that of a bladder scanner. Conduct a chart audit to determine previous outcome trends in bladder scanner use. Gather a consensus of provider opinions about the use of bladder scanners at the facility.
Review evidence-based practice data related to bladder scanner use. MY ANSWER To facilitate the best client outcomes, the performance improvement team should review available evidence-based practice data related to this task. This should provide the most accurate and comprehensive information on which to base policy and procedure decisions.
A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse plan to take? (Select all that apply.) Select an interpreter who is the same gender as the client. Ask the client's family members to interpret the information. Ensure interpreters provided by the facility have knowledge of medical terminology. Obtain informed consent from the client prior to requesting an interpreter. Choose an interpreter from the same ethnic background as the client.
Select an interpreter who is the same gender as the client is correct. The nurse should select an interpreter who is the same gender as the client to avoid embarrassment. Ask the client's family members to interpret the information is incorrect. The nurse should not ask the client's family members to interpret because they might not interpret medical terminology accurately. Ensure interpreters provided by the facility have knowledge of medical terminology is correct. To accurately relay medical information, interpreters should have specialized medical training. Obtain informed consent from the client prior to requesting an interpreter is incorrect. Informed consent is used for specific medical and surgical procedures. Obtaining the use of an interpreter would entail expressed or implied consent. Choose an interpreter from the same ethnic background as the client is correct. The nurse should select an interpreter that is from the same ethnic background as the client to prevent possible conflicts and differences in dialect.
A charge nurse in a long-term care facility is monitoring the activities of an assistive personnel (AP). Which of the following actions by the AP indicates that the charge nurse should intervene? Returns unopened supplies from a client's room to the storage room Obtains assistance when lifting an object that weighs 18.1 kg (40 lb) Double-bags a biohazard bag that is contaminated on the outside Stands with feet close together while transferring a client from the bed to a chair
Stands with feet close together while transferring a client from the bed to a chair MY ANSWER The AP should stand with feet wide apart while transferring a client from the bed to a chair to increase stability and prevent self-injury.
A nurse arrives for their shift and is assigned more clients than they feel is safe. The charge nurse states there are no other options due to a shortage in nursing staff. Which of the following actions should the nurse take? Request to float to another unit. Refuse the assignment and leave the unit. File an incident report with the risk manager. Submit a written complaint to the nursing supervisor.
Submit a written complaint to the nursing supervisor. The nurse should submit a written complaint to the nursing supervisor detailing their concern if they must accept an assignment for more clients than they feel is safe. This written complaint ensures that the facility is aware of the issue and indicates that the nurse made an attempt to address the situation.
A nurse is caring for a client who received a skin tear during a routine dressing change. After completing an incident report, which of the following actions should the nurse take? Document the completion of the incident report in the client's medical record. Submit the incident report to the nurse manager for review. Mail a copy of the incident report to the facility's attorney. Obtain the client's signature on the incident report.
Submit the incident report to the nurse manager for review. MY ANSWER The nurse should complete an incident report for unusual occurrences or variances in client care. The nurse manager should have the opportunity to review the information in order to begin the quality review process.
A nurse is preparing to care for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse plan to take first? Change the client's abdominal dressing. Remind the client to use an incentive spirometer. Administer prescribed analgesics to the client. Take the client's vital signs.
Take the client's vital signs. The first action the nurse should take using the nursing process is to collect data from the client. By obtaining the client's vital signs, the nurse can monitor the client's recovery and identify the presence of potential postoperative complications.
A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility? The client develops command hallucinations. The client displays transference toward the nurse. The client reveals a family history of schizophrenia. The client expresses feelings of low self-esteem.
The client develops command hallucinations. MY ANSWER Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility.
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance? The nurse on the prior shift administered the client's twice-daily antibiotic 1 hr after it was due. The nurse hears two assistive personnel discussing the client in a public elevator. The client reports they do not have advance directives. The client has a circular area of nonblanchable redness on their left heel.
The client has a circular area of nonblanchable redness on their left heel. A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on their left heel as a variance because this indicates the initial stage of a pressure injury and is not an expected outcome.
A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions demonstrates the nurse's role as client advocate? The nurse assists a client in communicating end-of-life decisions to the provider. The nurse personalizes client medication information to reinforce client teaching. The nurse implements a turn schedule to prevent client skin breakdown. The nurse consistently assigns the same staff to a client who has dementia.
The nurse assists a client in communicating end-of-life decisions to the provider. The nurse acts in the role of client advocate when protecting the client's legal and ethical rights.
A community health nurse is reinforcing teaching with a group of parents about home safety for children of various age groups. Which of the following information should the nurse plan to include? The risk of lead poisoning is greatest in 10-year-old children. The supine position is the safest for sleeping infants. Falls are the leading cause of injury in preschoolers. Air-popped popcorn is a recommended snack for toddlers.
The supine position is the safest for sleeping infants. MY ANSWER The nurse should reinforce that placing an infant in the supine position is recommended by the American Academy of Pediatrics to decrease the risk of sudden infant death syndrome (SIDS).
A nurse is participating on a committee that is revising the facility's policies and procedures for infection control. Which of the following instructions should the nurse recommend including in the facility's infection control manual? Double-bag linens prior to removing them from the client's room. Place sterile objects at least 1.3 cm (0.5 in) inside the edge of a sterile field. Apply a surgical mask to a client on contact isolation prior to transporting to radiology for an x-ray. Use a 1:10 bleach solution to clean blood spills.
Use a 1:10 bleach solution to clean blood spills. The nurse should recommend using a 1:10 bleach solution to decontaminate blood spills.
