Management of care1

Which room assignment would be most therapeutic for the nurse to make for a manic client who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.

1. Correct: A private room...to decrease stimulation.

A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what to the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures.

The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.

1. Correct: Safety must be maintained while the client is in this vulnerable state.

Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap before entering the operating room. 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.

1. Correct: The area outside the OR is restricted to personnel with surgical attire and coverings.

The RN on the unit tells the LPN/VN to perform the admission assessment on the newly admitted client. Which right of delegation did the nurse fail to consider? 1. The right task 2. The right direction 3. The right communication 4. The right supervision

1. Correct: The right task was not considered. The admission assessment must be completed by the RN.

Who often performs the responsibilities of a case manager? Select all that apply: 1. Physical therapist 2. Social worker 3. Primary healthcare provider 4. Nurse 5. Unlicensed assistive personnel

2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional.

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school.

2. Correct: The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with another nurse and ask the nurse to observe during the procedure.

The nurse notices that a client's bedside privacy curtain has been left partially open during the client's bath. Which is the best action for the nurse to take in order to ensure the client's right to privacy? 1. Inform the client that the curtain was left partially open and that the client may have been exposed at some point during the bath. 2. Close the privacy curtain to protect the client's right to privacy. 3. No action is necessary. The client did not notice the open privacy curtain. 4. No action is necessary. There are only a few visitors on the unit during this time of the morning.

2. Correct: The curtain should be closed as soon as the opening is noticed to protect the client's right to privacy.

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply: 1. Child dying with leukemia. 2. Teenager with sickle cell disease in for pain management. 3. Child diagnosed with idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2., 3., & 5. Correct: The nurse should be given an assignment similar to the type of clients and skill level the nurse is accustomed to. Therefore, the choices should be these three clients. Even though one of the clients has leukemia, the child is being treated for stomatitis, not the leukemia.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

3. Correct: The best action by the nurse would be to itemize the valuables, place in an envelope, and put in the hospital safe.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be inappropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency

4. Correct: This client has adrenal insufficiency. It occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones are lacking. This puts the client at risk for fluid volume deficit and shock.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Call and ask the primary healthcare provider to visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the primary healthcare provider explained those options yesterday.

1. Correct: The client should be told about the surgical procedure, the options available,and the benefits and risks of each treatment modality. Surgery should be delayed until the client is sure of decision.

The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply: 1. Weigh QD 2. IV of normal saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone DHEA sulfate 5 mg by mouth every other day

1. & 4. Correct: Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".

A night shift nurse receives report from the day shift nurse when the day nurse states, "I have an appointment and I need to leave. Can you get the rest of the client's information from the medical records?" Which client right is violated by the day nurse? 1. Right to reasonable continuity of care 2. Right to confidentiality 3. Right to considerate and respectful care 4. Right to make decisions about the plan of care and proposed treatment

1. Correct: An incomplete or uninformative client report from one healthcare provider to the next violates the client's right to reasonable continuity of care.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. I understand. Should I ask them to come to the hospital to discuss this with the primary healthcare provider? 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. You have a limited amount of time to make this decision, so let me help you.

1. Correct: The client's family is important to her, especially her sons and their opinions regarding decisions.

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with transient ischemic attack.

1. Correct: This is the most stable client to give to the nurse who was transferred from the neonatal unit.

What would be the most appropriate room assignment for the charge nurse to make for a school age child with seizures whose family cannot stay with the child at all times? 1. A private room away from the elevator and nurse's station. 2. A semi-private room near the nurse's station. 3. Rooming with a preschooler admitted with behavioral problems. 4. Rooming with a school age child admitted for developmental delays.

2. Correct: A semi-private room near the nurse's station would be the best choice for this client.

The nurse is taking report on a busy unit. The nurse recognizes that three admissions were taken during the night shift, one nurse called in sick, and the clients on the unit are very ill. What action should the nurse do first to ensure client safety? 1. Take report on the most critical clients. 2. Call in another nurse to improve the staffing pattern. 3. Ask each nurse to take more clients. 4. Call the nursing supervisor to request immediate help.

4. Correct: The nurse should call for immediate help so that a safe care environment is maintained for all clients. The nursing supervisor may be able to lend a hand until another nurse can come in to work.

Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Reporting lab results to the client 2. Measurement of intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse

2. Correct: Measurement of intake and output is a function of an unlicensed assistive personnel, and these tasks may be delegated.

A child is admitted to the hospital with a temp of 102.2°F/ 39.0°C, lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Blood cultures times two 2. Rocephin 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr

1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high.

Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Pacemaker with history of heart failure. 2. Colon resection with new onset a-fib. 3. Status post CABG with atrial flutter. 4. Chest pain with history of heart failure.

1. Correct: Yes, this client is the least critical.

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."

2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence.

The supervisor notifies the charge nurse on the pediatric floor that a 6 month old is being admitted with acute gastroenteritis. What room assignment is most appropriate for the nurse to make for this client? 1. Private room. 2. Rooming with a 2 month old admitted with bacteremia. 3. Rooming with a 9 month old with pneumonia. 4. Rooming with a 6 month old with urinary tract infection.

1. Correct: Gastroenteritis is contagious, so if at all possible, place the child in a private room, so other children would be less likely to contract the gastroenteritis.

A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the RN delegate to an unlicensed assistive personnel (UAP)? 1. Reminding the client to apply the CPAP at bedtime 2. Obtaining oxygen saturation levels every three hours 3. Teaching the client how to turn on the CPAP machine 4. Assessing for fatigue or depression caused by poor sleep

1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention.

Which client in the Labor, Delivery, Recovery, Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke". 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.

1. Correct: Minus two stations is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client is wishes to leave. 2. Make arrangements for a commitment hearing. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step involves calling the primary healthcare provider.

The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Discuss the threat with the treatment team. 2. Call the wife immediately to report the intent. 3. Ignore the threat because the client may change his thinking. 4. Tell the client that he shouldn't make threats like that.

1. Correct: The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed.

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? 1. Providing information to the client and fostering a sense of security. 2. Promoting client compliance. 3. Assuring client safety. 4. Ensuring the client's wishes for treatment are followed.

1. Correct: The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and to foster a sense of security.

A client with an executed advance directive specifying "do not resuscitate, do not intubate" in the medical record becomes unresponsive during a bed bath. The unlicensed assistive personnel (UAP) activates the hospital code system and initiates CPR. Which action by the nurse is most important in protecting the client's right to self-determination? 1. Instructing the UAP to stop CPR. 2. Assisting the primary healthcare provider with the intubation process. 3. Assisting the UAP in placing the backboard under the client to facilitate compressions. 4. Instructing the UAP to retrieve the crash cart.

1. Correct: The nurse should immediately inform the UAP and the code team of the client's code status and ask the UAP to stop CPR.

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the GYN floor. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. Correct: This client needs a private room so she can feel free to grieve and have family members stay with her for support. She should be transferred to a GYN unit so the sights and sounds of the maternity unit do not contribute to her pain.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical.

A newly appointed nurse manager on the renal unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. How should the nurse manager handle this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the system will be implemented and all who do not follow the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

1. Correct: Yes, get everyone together and discuss the problem and find areas of compromise where possible.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? Select all that apply: 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lyphoma 5. Post-partal with HELLP syndrome

1., & 2. Correct: These clients are basically medical-surgical clients.

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply: 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Provide mandatory in-service sessions on infection control for every shift.

1., 2., 3., 4., & 5. Correct. Each of these actions can be taken by the nurse manager. The staff needs further education, reminders, and follow-up observation.

Which members of the multidisciplinary team should the nurse recognize as being responsible for collaboration in client care? Select all that apply: 1. Primary healthcare provider 2. Primary care nurse 3. Dietician 4. Physical therapist 5. Case manager

1., 2., 3., 4., & 5. Correct: All members of the multidisciplinary health care team are responsible for a collaborative care approach to client care. Multidisciplinary care has significantly improved client outcomes and decreased client length of stay in healthcare facilities

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? Select all that apply: 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided.

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply: 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1., 3, & 5. Correct. These are written correctly.

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply: 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1., 3, & 5. Correct. These are written correctly.

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book crushing the tablet and mixing it into 3 ounces of applesauce, the student nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest the new nurse reconsider client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce new food during an illness.

A nurse wants to find a better way to perform oral care on unresponsive clients. What is the first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Correct: The best thing for the nurse to do is to identify a problem, as this is the person directly caring for clients. Then, get with an experienced person who can research "best practice" regarding the issue.

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? Select all that apply: 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics

2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable.

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? 1. Identify a new goal for the client since this one has not been achieved. 2. Consider new nursing interventions for achievement of the goal if the condition still warrants it. 3. Determine that the nursing interventions were performed as planned. 4. Allow more time for achievement of the goal.

3. Correct: First, the nurse will want to determine that the interventions were performed. If they were not carried out, the goal could not be achieved.

Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3. Correct: The child having respiratory difficulty should be seen first.

The nurse is preparing to discharge four clients from the unit during the shift. Which client is most likely to warrant a referral to other agencies or community outreach programs? 1. 45 year-old married female who has returned to pre-hospital level of functioning 2. 50 year-old client who has had elective surgery. 3. 72 year-old client with diabetes who has limited mobility. 4. 80 year-old client who has recovered from a diagnosis of delirium.

3. Correct: The elderly client who has limited mobility is likely to need referrals at the time of discharge, whether to physical therapy, home health, or other agency.

What assignment would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client.

The charge nurse notices that a certain staff nurse verbally attacks a client that was admitted with a history of being sexually abused. Further investigation reveals that the staff nurse was sexually abused as a child. Which action would the charge nurse take in making assignments? 1. Assign the nurse to this client, so the charge nurse may receive feedback from the client about the nurse's behavior. 2. Allow the nurse to decide if the nurse will take care of the client. 3. Assign another nurse to the client. 4. Co-assign the client to the nurse and a licensed practical nurse.

3. Correct: The nurse does not need to be assigned to care for the client. Assigning the client to the nurse could be detrimental to the client. It would be safer for the client to be assigned to someone else. This would be fairer to the nurse and to the client.

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign the new nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Correct: The nurse is the only one who can assess.

The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first? 1. Report the incident to the nursing supervisor. 2. Write up a variance report about the incidence. 3. Instruct the students that this is a violation of HIPAA. 4. Notify the students' faculty regarding the violation.

3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified.

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? 1."Ignore him and get the rest of your work done. Someone else can care for him the rest of the day." 2.."He has a lot of problems. You need to have patience with him." 3."He may be scared and taking it out on you. Let's talk to figure out what to do next." 4."I will talk with him and try to figure out what to do or what the problem is."

3."He may be scared and taking it out on you. Let's talk to figure out what to do next."

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no contraindications to taking care of the client with shingles.

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? Select all apply: 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101 o F (38.3 o C). 5. Monitor intake and output every hour.

4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN.

The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority). 1.Oxygen 2 liters nasal cannula 2.Finger stick before each meal and at bedtime 3.Blood and sputum cultures 4.Ceftriaxone (Rocephin) 1 gram every 12 hours 5.IV normal saline at 100 mL/hr

1,3,5,4,2 For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the client's oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete.

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

1. Correct: Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented.

The nurse is supervising the care of a client with a closed head injury. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Assist with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measures urinary output for past hour. 4. Turns off room lights.

1. Correct: Stop this. No valsalva as this will increase ICP. TCDB increases intrathoracic pressure which increases ICP.

The nurse suspects that a neighbor is abusing their child. The nurse has noticed bruises on the child's face, the backs of the hands, and the tops of the feet. When questioned, the parents state their child is just clumsy. The nurse reports possible abuse to Child Protective Services. How would a nurse peer evaluate this nursing action? 1. The nurse is serving as an advocate for the child. 2. The nurse is over involved in the business of the neighbors. 3. The nurse has no right to interfere with private issues. 4. The nurse should speak to the parents privately about any concerns.

1. Correct: The action is appropriate. The nurse is serving as an advocate for the child who cannot advocate for self.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Call the primary healthcare provider and ask that they visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the primary healthcare provider explained those options yesterday.

1. Correct: The client should be told about the surgical procedure, the options available,and the benefits and risks of each treatment modality. Surgery should be delayed until the client is sure of decision.

The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Discuss the threat with the treatment team. 2. Call the wife immediately to report her husband's intention. 3. Ignore the threat because the client may change his thinking. 4. Tell the client that he shouldn't make threats like that.

1. Correct: The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed.

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. What information is vital for the nurse to provide? Select all that apply: 1. "Dr. Smith, this is nurse Adams, RN. I am calling about your client Jane Doe at ABC hospital." 2. "Jane Doe is having increasing dyspnea and is complaining of chest pain." 3. "Ms. Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"

1., 2., 3., 4., & 5. Correct: First, the nurse should identify self, agency, and client. Then deliver the Situation, Background, Assessment and Recommendation (SBAR) technique. SBAR has become the Joint Commission's stated industry best practice for standardized communication in healthcare; it provides a seamless, clear structure for communicating via spoken delivery. Each of these statements fulfills appropriate SBAR requirements.

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation.

Which tasks are appropriate for the RN to assign to the LPN/VN on a Labor, Delivery, Recovery, Postpartum Unit (LDRP)? Select all that apply: 1. Assessing a primipara admitted to rule out labor 2. Obtaining vital signs on a client 15 minute after delivery 3. Assisting a primipara with breastfeeding 4. Administering terbutaline to a client in preterm labor 5. Inserting an indwelling urinary catheter into a postpartum client who has not voided in 6 hours

2., 3., 4., & 5. Correct: Although the client who just delivered is still at high risk for complications, the LPN/VN can take vital signs. The RN would still need to evaluate. Breastfeeding is considered a routine teaching that the LPN/VN can reinforce on this type of unit. LPN/VNs can administer medications such as terbutaline. The LPN/VN can insert an indwelling urinary catheters.

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what should the nurse do first? 1. Consult with the primary healthcare provider about the pain medication. 2. Carefully assess the client and the level of pain. 3. Gradually increase the time between pain medication. 4. Encourage the client to wait longer before requesting the medication

2. Correct: The nurse should carefully assess the client. The nurse must serve as an advocate for the client.

The nurse is working in a small hospital in a rural town. A nurse from the ED calls the floor to ask about a client who was admitted from her neighborhood. The nurse answering the phone is worried that she will offend the ED nurse. What should the nurse do? 1. Answer the question for the nurse as she is employed by the hospital. 2. Refrain from answering the question, as the nurse is not in a position to "need to know." 3. Tell the nurse that the client is no longer in the hospital. 4. Give the nurse the client's family's phone number.

2. Correct: The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation. The floor nurse should simply state the limit that she cannot give any information about a client to someone who is not in the position for "need to know".

A client is to undergo an endoscopy in the client's room. The gastroenterologist asks the general medical unit nurse to prepare and then give the client propofol 10 mL slow IVP until sedation is achieved. What action should the nurse take? 1. Administer the propofol. 2. Draw up the propofol and give it to the gastroenterologist to administer. 3. Inform the gastroenterologist that giving propofol is outside the nurse's scope of practice. 4. Call the state Board of Nursing to ask if it is appropriate for a nurse to give propofol.

3. Correct. Propofol administration is outside the scope of practice for general floor nurses. Nurses with specialty training, particularly in critical care units, often give propofol to clients who are intubated and on the ventilator. These clients have an airway. The gastroenterologist cannot monitor the client adequately while performing the procedure.

The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best? 1. Call the staff nurse in and tell the nurse this must not happen again. 2. Have the other staff talk to the nurse and insist that the nurse improve. 3. Call the staff nurse in for an interview to investigate the problem and possible solutions. 4. Assign the nurse a mentor to make sure the nurse gets to work on time.

3. Correct: Give the nurse an opportunity to explain and then together work on a plan of resolution.

The home health nurse has been working with an elderly African American woman for six months. Recently, she has become withdrawn and is not attending church. The client had previously spoken to the nurse about the importance of faith in her life. The nurse thinks that a referral may be appropriate. Which referral can the nurse make independently? 1. Counselor 2. Social worker 3. Client's minister 4. Case worker

3. Correct: The client may benefit from involvement of the minister. Perhaps the client needs transportation to church, or needs increased contact with the church family. Church is typically important to the African American client

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine. Promise that you won't tell the director." What should the nurse do? 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home.

3. Correct: The nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired.

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old that had an appendectomy 6 hours ago. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a tracheostomy admitted for UTI.

3. Correct: The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else.

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse see first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

4. Correct: Being restless is an early sign of hypoxia. Oxygen may be necessary. Remember the ABCs.

Which client should the labor nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+. 2. Multigravida on po terbutaline with a pulse rate of 110. 3. Primigravida on IV oxytocin with contractions every 3-4 minutes. 4. Multigravida on po methyldopa with a blood pressure of 142/86.

4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

4. Correct: It would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence."

A nurse delegated ambulation of a client to the unlicensed assistive personnel (UAP). The next day, it was noted by the family that the client was not ambulated on the nurse's shift. What delegation error was made by the nurse? 1. Failure to delegate to the right person. 2. Failure to delegate under the right circumstance. 3. Failure to communicate. 4. Failure to supervise and evaluate adequately.

4. Correct: The nurse failed to monitor and follow up with the UAP. Supervision and evaluation are part of the 5 rights of delegation.

A nurse delegated ambulation of a client to the unlicensed assistive personnel (UAP). The next day, it was noted by the family that the client was not ambulated on the nurse's shift. What delegation error was made by the nurse? 1. Failure to delegate to the right person. 2. Failure to delegate under the right circumstance. 3. Failure to communicate. 4. Failure to adequately supervise and evaluate.

4. Correct: The nurse failed to monitor and follow up with the UAP. Supervision and evaluation are part of the 5 rights of delegation.

A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Woman with PIH at 34 weeks gestation.

4. Correct: This client has symptoms of preeclampsia and should be either in a private room or in a quiet, darkened room to minimize stimuli that could trigger seizures. A roommate requiring a similar environment would be most appropriate when there are no private rooms available.

Which nurse would be the most appropriate for the charge nurse to assign to a 5 year old admitted in sickle cell crisis? 1. The nurse who is taking care of a 4 year old who had a routine appendectomy, a 3 year old who had bowel surgery, and a 10 year old with developmental delays. 2. The nurse who is taking care of a 6 month old with Respiratory Syncytial Virus (RSV), a 3 year old with exacerbation of asthma, and a 6 year old with a urinary tract infection for 2 weeks. 3. The nurse taking care of a 9 year old newly diagnosed with diabetes, a 6 year old with end stage renal disease, and a 2 year old with contact dermatitis. 4. The nurse taking care of a 8 year old with skeletal traction, a 5 year old with cerebral palsy, and a 12 year old with cystic fibrosis.

1. Correct: The nurse taking care of the appendectomy, bowel surgery, and developmentally delayed child has the set of clients that is less busy and has fewer client care needs.

The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? Select all that apply: 1. Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.

1., 3., 4. & 5. Correct: Many times factories are placed in communities where people are not aware of the hazards. The underrepresented and poor need the nurse as advocate. Forums encourage wider participation of all community members and give the community more information about the consequences of the pollution. The public health nurse advocates for the health of the entire community. Individuals in the communities where factories are located could give first-hand information about health or other issues related to the factory placement. Printed reports, depending on the source, may contain false information.

A nurse assigned to an HIV-positive client refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 1. Re-assign the client to a nurse who does not mind caring for HIV-positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV-positive clients.

2. Correct: Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem, but the ethical obligation to care for all clients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice.

The nurse notices that the primary healthcare provider, who has been looking at his client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. The nurse should immediately log the primary healthcare provider off the facility's health information system. 2. The nurse should immediately minimize or hide the screen so that the client information is not longer visible, and then ask the primary healthcare provider if he will be returning to the computer work station. 3. The nurse should do nothing. The primary healthcare provider is a member of the healthcare team and is responsible for information accessed on the hospital's health information system. 4. The nurse should read the health information that the primary healthcare provider left visible on the computer screen to attempt to determine if the primary healthcare provider was finished.

2. Correct: It is appropriate and polite to minimize or hide the screen so that the information is no longer visible, then inquire whether the user will be returning to the computer work station.

Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 1. Adult with severe upper gastric pain. 2. Child with stridor and excessive drooling. 3. Adult in severe pain due to a dislocated shoulder. 4. Child with fever of 103ºF (39.44 °C) and blood streaked sputum.

2. Correct: The child with stridor and excessive drooling is in respiratory distress from epiglottitis and should be seen first: ABCs.

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

2. Correct: This client would not be a risk and could be cared for on the antepartum/postpartum floor.

While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.

3. Correct: A new nurse should assess this client first to check her fundus. If the fundus is boggy, a fundal massage will need to be done. If the fundus is not boggy (contracted), the blood running down the legs is normal, as blood pools in the vagina while the client is lying down. The peripad can not contain all the blood upon standing.

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.

3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to primary healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is the deception involved. The healthcare provider lies to the client. Deceit is harmful to both clients and healthcare professionals. When discovered (and it usually is), it may permanently damage a client's trust in healthcare professionals. There is always a better way to assess and treat clients with pain than to administer a placebo.

The 3-11 shift charge nurse is making rounds on the pediatric unit. The charge nurse notes that a 12 year old admitted at 11 am was assigned to a LPN/VN during the 7-3 shift. What would be the most appropriate action by the charge nurse? 1. Assess the client and document problems on the care plan. 2. Assign a RN to initiate and document a plan of care on this client. 3. Check to see if a RN verified the assessment and signed the nursing assessment form. 4. Check to see if the family is satisfied with having a LPN/VN assigned to care for client.

3. Correct: The nursing assessment should be completed and verified by an RN within 8 hours of admission. The nurse carrying out the assessment should initiate a plan of care as well.

The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first? 1. Report the incident to the nursing supervisor. 2. Write up a variance report about the incidence. 3. Instruct the students that this is a violation of HIPPA. 4. Notify the students' faculty regarding the violation

3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified.

Case managers use clinical pathways in the process of evaluating and coordinating client care with the multidisciplinary team. What is a clinical pathway? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American Nurses Association or the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider orders for client care, which expedite the order process and can be customized to individual clients. 4. A set of practice guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse's role includes assessment of vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated.

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement regarding the dressing change. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the manager is not caught in the middle. They will be able to come up with solutions together or the manager can mediate.

Which nurse is providing cost effective care to a client? Select all that apply: 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.

1., 2., 3. & 4. Correct: In comparison to conventional care, palliative care is considered just as cost effective in reducing unnecessary utilization of resource. Palliative care is efficient, effective client-centered care. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed on the day of discharge, and discharge could be delayed. This is costly. Cost-effective services include counseling to quit cigarette smoking, colonoscopies, beta-blockers for patients after heart attacks. These are well-established interventions that work and are cost-effective. Two cost-effective preventive interventions are childhood immunization and counseling adults on the use of low dose aspirin.

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? Select all that apply: 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension of license or loss of license to practice nursing. 4. Suspension of license or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions.

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? Select all that apply: 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic in for bowel training.

1., 2., 3. Correct: It would be best to assign these clients to the RN as they will require more frequent assessment due to diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? Select all that apply: 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes

1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The plate guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip.

All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first? 1.62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 2.79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10 3.70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery 4.67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing

1.62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life-threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression.

A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice? 1.A female interpreter who does not know the client 2.A female neighbor of the client who is also from Bosnia 3.The client's adult daughter 4.A Bosnian male, who is a certified medical interpreter

1.A female interpreter who does not know the client When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client.

The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? 1.All employees participate in systematically working toward common goals 2.It is a reactionary approach used to investigate the root cause of a problem 3.Top administrators are responsible for establishing plans for problem management 4.It is an incident management technique that focuses on employee retention

1.All employees participate in systematically working toward common goals TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top administrators. It is a proactive, not reactive, approach to solving problems.

The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? 1.Complete and accurate documentation of assessments and interventions 2.Clinical specialty certification by an accredited organization 3.Above-average performance reviews prepared by nurse manager 4.Sworn statement that health care provider orders were followed

1.Complete and accurate documentation of assessments and interventions

The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate? 1.Encourage the client to discuss this decision with the health care provider and family 2.Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time 3.Tell the family members that the client's preference is to go home to die 4.No action is needed at this time unless the client repeats the statement to another caregiver

1.Encourage the client to discuss this decision with the health care provider and family The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill.

A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) 1.Family preferences 2.Reconciliation of medications 3.Poor communication among providers 4.Excellent primary care 5.Client health status

1.Family preferences 3.Poor communication among providers 5.Client health status Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.

The charge nurse reviews nursing roles and functions with a newly-hired licensed practical nurse (LPN). The LPN asks for more information about the role of the Minimum Data Set (MDS) coordinator. Which statement best explains the role of the MDS coordinator? 1.Interacts with health care staff to coordinate care processes of client assessment and care planning 2.Reviews admissions, diagnostic tests and treatments ordered by physicians 3.Reviews charts to maximize the cost efficiency of services 4.Works with families to help their loved ones transition into the nursing home

1.Interacts with health care staff to coordinate care processes of client assessment and care planning The MDS Coordinator is typically an RN who potentially interacts with staff across the nursing home to coordinate care processes of resident assessment and care planning. This person will complete and submit the federally-mandated MDS form to the Center for Medicare and Medicaid Services (CMS). A utilization review committee reviews admissions, diagnostic procedures, and treatments.

The MDS coordinator, who is a full time registered nurse, completes the minimum data set (MDS) for a new admission to a skilled nursing facility. Why does the nurse complete the MDS? (Select all that apply.) 1.It provides a standardized set of essential clinical and functional status measures 2.It will be used to measure outcomes of nursing care 3.It is required for all clients in a Medicare- or Medicaid-certified nursing facility 4.It's used to direct the care that may be performed by nursing assistants 5.It is required by the board of trustees

1.It provides a standardized set of essential clinical and functional status measures 3.It is required for all clients in a Medicare- or Medicaid-certified nursing facility The Minimum Data Set (MDS) is a standardized uniform comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law (P.L.100-203). It is a component of the federally-mandated Resident Assessment Instrument (RAI) and must be completed for any individual staying more than 14 days in that facility. The MDS is designed to help nursing homes thoroughly assess individuals in a standardized, comprehensive and reproducible manner; potential problems, strengths and preferences are identified using the MDS. The MDS cannot measure outcomes of care.

The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the ED? 1.Notify the nursing supervisor and request additional staff 2.Prepare the trauma room and select supplies 3.Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank 4.Activate the disaster plan

1.Notify the nursing supervisor and request additional staff The ED charge nurse needs to assess, supervise and coordinate staff and to maintain full readiness of ED. The priority is for the ED charge nurse to notify the nursing supervisor that additional nursing staff will be needed. Preparing the trauma room will be next. The clients will need to be assessed prior to the administration of any IV solution and/or blood products. There is no need to activate a disaster plan for a two car accident.

The charge nurse is assigning duties to the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? 1.Provide stoma care for a client with a well-functioning ostomy 2.Care for a recent complicated double barrel colostomy 3.Assess the function of a newly created ileostomy 4.Teach the initial ostomy care to a client and family members

1.Provide stoma care for a client with a well-functioning ostomy The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency, and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN.

The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? 1.Reduce readmissions to the hospital 2.Increase satisfaction with nursing care 3.Reduce insurance costs 4.Increase client understanding of discharge instructions

1.Reduce readmissions to the hospital Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.

The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) 1.The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish 2.The UAP applies moisture barrier cream to the client's excoriated perianal area 3.The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall 4.The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor 5.The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday

1.The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish 3.The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall 4.The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.

The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse? 1.The client's self-report of pain is the most important consideration 2.Nurses should not prejudge a client's pain using their own values 3.Clients have the right to have their pain relieved 4.Cultural sensitivity is fundamental to pain management

1.The client's self-report of pain is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. This is why the self-report is the most reliable way to determine a client's pain. Nurses should apply ethical standards, such as respect for autonomy (the right of people to make their own decisions about healthcare), when assessing pain. The other statements are correct but they are not the most important considerations.

The emergency department called the LDR to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 1. Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. 2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. 4. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

2. Correct: Obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPN/VN.

A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units of blood. What should the nurse do? 1. Prepare the client for the administration of blood. 2. Explain to the primary healthcare provider that the client's faith prohibits blood transfusions. 3. Explain to the client that the blood transfusions are needed for return to health. 4. Try to convince the client to accept the transfusions.

2. Correct: The nurse must serve as the client's advocate. This client's religion prohibits blood transfusions.

The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? 1. Tell the client that the behavior is inappropriate. 2. Accompany the client to the TV room on the unit. 3. Allow the male client to handle the situation. 4. Continue with the unit routine.

2. Correct: This behavior must be interrupted, as the rights of other clients are being jeopardized. The other clients are being exploited by the manic client.

The nurse is working with a client in the home environment. The major issue of concern for the client is the prognosis for the cancer that was diagnosed three months ago. When the nurse visits, the client asks, "How do I know if what I am reading on the World Wide Web is true and correct about cancer treatment?" Which response by the nurse indicates understanding of the evaluation process for web based medical information? 1. Most information about medical problems is up to date. 2. Look for credible websites such as .gov, .edu, and .org. 3. If there are ads on the page, the site is probably not a credible one. 4. Look for easy navigation of the site.

2. Correct: Websites that are authored by government agencies, educational institutions, or non-profit organizations are considered to be credible websites. Other criteria are important as well when evaluating a website.

The unit nurse manager would like to change the way shift report is conducted on the unit. Which activity would be most beneficial in creating this change? 1. Assign several research articles on the "art of shift report" as reading for the staff to complete and discuss. 2. Have the staff float to other units in order to observe the various ways the institution performs shift report. 3. Introduce the idea at a staff meeting and gather input on possible methods with pros and cons; then implement a change. 4. Announce the change to all the staff and the implementation date of the planned change.

3. Correct: Allowing the staff to have input and offer possible solutions is the best choice.

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of lifestyle changes 4. Verbalization of energy-conservation techniques

3. Correct: On admission, the best starting point is to survey what is good and what needs to be changed.

The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee? 1."What degree of supervision for basic care do you think you need?" 2."What types of complex client-care tasks or assignments do you prefer?" 3."Let's review your skills checklist for type and level of skill for tasks." 4."Let's talk about your comfort zone for working independently."

3."Let's review your skills checklist for type and level of skill for tasks." The nurse needs to know that the potential employee has competence in certain tasks that are common on the unit. One way to do this is to do mutual review of the agency list of skills. The other questions might be asked during the skills checklist review.

The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients? 1.An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation 2.An elderly person who was admitted three hours ago with a diagnosis of cyclothymia 3.A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder 4.A young adult who was admitted 24 hours ago for treatment following detoxification

3.A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder These findings suggest depression. The most therapeutic milieu for this client includes double occupancy with someone who has similar issues and/or whose condition is more stable. A secondary consideration is matching roommates' ages as closely as possible, because they potentially would share similar developmental challenges and needs. The most stable client is the one with persistent depressive disorder. Cyclothymia is an illness that's similar to bipolar disorder and disruptive mood dysregulation disorder is characterized by irritability and episodes of extreme, out-of-control behavior.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model? 1.An appointed board oversees any administrative decisions 2.Non-nurse managers supervise nursing staff in groups of units 3.Nursing departments share responsibility for client outcomes 4.Staff groups are appointed to discuss nursing practice and client education issues

3.Nursing departments share responsibility for client outcomes Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.

A national emergency situation exists in a small coastal town where there have been massive flooding and casualties. The damaged hospital is still receiving victims for treatment. Several nurses have volunteered to triage victims during this time. Family members have been asking about the status of loved ones who may have possibly been to the hospital. What action should the nurses take? 1. Tell the family members that they cannot give any personal information about clients. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Give information to the family.

4. Correct. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions.

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Case manager

4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client.

Two new graduates are working in a busy emergency department (ED). With limited experience, the nurses may need to consult experts to assist them with client care. Which management decision impedes access to needed information? 1. Scheduling both experienced and less experienced staff on the same shift. 2. Assigning preceptors to new grads. 3. Instituting an internship for nurses beginning employment in the ED. 4. Blocking access to the internet on all ED computers.

4. Correct: Blocking access to the internet keeps employees, both experienced and inexperienced, from finding new and innovative treatments. While some employers allow access, many managers are focused on task completion and don't encourage exploration of nursing literature.

A client with cancer refuses treatment and asks about options for hospice home care. The clients' daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. Self-determination 2. Ability to decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care

4. Correct: The client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment.

The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first? 1. Client with somatoform disorder. 2. Client with depression. 3. Client with panic attacks. 4. Client on suicide precautions.

4. Correct: The client on suicide precautions should be seen first. The elderly are particularly at risk.

Which client could the charge nurse reassign to an LPN/VN? 1. Eight year old in diabetic ketoacidosis 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction

4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly all others could have IVF needs and medications that would require skill from an RN.

A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? 1. Your children are correct. The open heart surgery is the best thing for your health. 2. You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery. 3. I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns.

4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings, and to demonstrate compassion and a willingness to understand. This presents an opportunity for additional communication to help answer some of the client's questions, or set up a client-family conference with the client, the client's family, and the primary healthcare provider.

A client who is unconscious is brought to the emergency department by an ambulance. What document should be given priority to guide the approach for the care of this client? 1.The national statement of client rights and the client self-determination act 2.The clinical pathway protocol of the agency and the emergency department 3.Orders written by the health care provider in the emergency department 4.A notarized original of the advance directive brought in by the partner

4.A notarized original of the advance directive brought in by the partner This document specifies the client's wishes of what actions are to be taken when the client becomes unable to make health care decisions. The advance directive often includes a living will and the power of attorney to whom will make the decisions for the client. The next document that would take precedent are the orders written by the heath care provider. The clinical pathways are used to evaluate the client's progress during therapy.

Which client should the nurse see first after receiving report on assigned clients? 1. Crushing chest pain. 2. Needing an IV started for the administration of blood. 3. Crying with pain after back surgery. 4. Waiting to go for a cardiac catheterization.

1. Correct: The client reporting crushing chest pain is probably having an MI and should be seen first. This client takes priority over the other three clients.

The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restrictive to most restrictive? Place in correct order from least restrictive to most restrictive. *Four point soft cloth restraints. *Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. *Place client in the isolation room with staff observation. *Walk the client out to the courtyard. *Restrain client's arms with wrist restraints. *Take the client to the client's room for a time out.

*Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. * Walk the client out to the courtyard. * Take the client to the client's room for a time out. * Place client in the isolation room with staff observation. * Restrain client's arms with wrist restraints. * Four point soft cloth restraints.

After reviewing her assignment, the LPN/VN tells the RN her assignment is very unfair and requests that some of her clients be redistributed to the other staff. What should the RN do? 1. Ask the LPN/VN what her concerns are regarding her assignment. 2. Remove one of the LPN/VN's clients and take the client as part of her load. 3. Encourage the LPN/VN to use her teamwork skills in caring for her clients. 4. Explain to the LPN/VN that everyone has a heavy load and to change the assignments now would not be possible.

1. Correct: Explore her concerns, this is most therapeutic.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Correct: The assessment findings will allow each person to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin.

A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Which primary healthcare provider prescription will the nurse perform first? 1. Initiate oxygen at 2 liters/nasal cannula. 2. Start an IV of NS at 150 ml/hr. 3. Insert NG tube to low suction. 4. Attach client to the ECG monitor.

1. Correct: The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because of decreased blood volume.

A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. Assign specific staff to check on each client during end-of-shift report. 2. Place newly admitted clients close to the nursing station. 3. Monitor level of suicide precaution needed on each client daily. 4. Ask clients to check on each other throughout the shift.

1. Correct: Assigning specific staff to client checks will assure that someone is responsible each shift, thus maintaining the client's right to a safe environment.

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, I know. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

1. Correct: The experienced nurse demonstrates an understanding of appropriate staff supervision by answering that the charge nurses are accountable for supervising client care and safety after they have made client care assignments, and by clarifying that the charge nurses are probably attempting to be supportive of the new graduate nurse.

An experienced RN and LPN are working with a new graduate nurse. The graduate has just recently passed NCLEX. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor may act as a barrier to delegation? 1. Lack of experience of the new graduate. 2. The level of education of the staff. 3. Lack of comfort with conflict. 4. Worry about being perceived as lazy.

1. Correct: The most likely reason in the described scenario is lack of experience of one of the team members.

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving TPN. 3. Two year old taking only liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.

1. Correct: This child has been receiving only liquids for more than 3 days and would be a nutritional risk.

The charge nurse sends a nursing assistant to help an RN with admission of a client with multiple health problems. Which of the following tasks would be appropriate to delegate to the nursing assistant? (Select all that apply.) 1.Collect a urine specimen 2.Obtain routine vital signs (temperature, pulse, respirations, blood pressure, oxygen saturations) 3.Observe and document the client's responses to ambulation to the bathroom 4.Orient the client to the room 5.Assist the client to change into a gown

1.Collect a urine specimen 2.Obtain routine vital signs (temperature, pulse, respirations, blood pressure, oxygen saturations) 4.Orient the client to the room 5.Assist the client to change into a gown Obtaining routine vital signs and answering call lights are universal activities that a nursing assistant can perform, regardless of the setting. A nursing assistant may help with activities of daily living (ADLs) and can collect basic specimens, eg., urine for urinalysis. Although nursing assistants can document information they cannot assess clients.

The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time? 1.Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." 2.State strongly: "Stop. Tell me why there's no urine in the tubing." 3.In a speaking tone of voice, explain: "The tubing is probably in the vagina." 4.Ask the student in a calm voice: "Did you do something wrong?"

1.Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." When no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. This catheter can be left in place and used as a landmark indicating where not to insert the new, sterile catheter. The best approach is for the nurse is to calmly remind the student about this technique and offer assistance. The other options are unprofessional and/or they may upset the client and the student.

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate.

The nurse delegated feeding of an elderly client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that she didn't do her job. 4. Provide a between meal supplement to the client.

2. Correct: Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served.

The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse for her password so that he can get the information. What should the nurse do? 1. Enter the personal password and allow the volunteer to retrieve the information. 2. Tell the volunteer that only staff have access. 3. Tell the volunteer the password and allow him to retrieve the information. 4. Obtain the information at the end of the shift.

2. Correct: Health information is private. Only those who are involved with the care of the client have access to it.

The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse for login information so that he can get the information. What should the nurse do? 1. Enter the personal password and allow the volunteer to retrieve the information. 2. Tell the volunteer that only staff have access. 3. Tell the volunteer the password and allow the volunteer to retrieve the information. 4. Obtain the information at the end of the shift.

2. Correct: Health information is private. Only those who are involved with the care of the client have access to it.

The nurse is working in a small hospital in a rural town. A nurse from the ED calls the floor to ask about a client who was admitted from her neighborhood. The nurse answering the phone is worried that she will offend the ED nurse. What should the nurse do? 1. Answer the question for the nurse as she is employed by the hospital. 2. Refrain from answering the question, as the nurse is not in a position to "need to know." 3. Tell the nurse that the client is no longer in the hospital. 4. Give the nurse the client's family phone number.

2. Correct: The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation. The floor nurse should simply state the limit that she cannot give any information about a client to someone who is not in the position for "need to know".

A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which is the best action by the nurse? 1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information related to the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.

2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when his feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.

2. Correct: This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. Her skin assessment indicates a circulation problem.

The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment? 1."Which clients should I see as I begin my day?" 2."Which groups are at the greatest risk for problems?" 3."Which physicians will I be more closely collaborating with?" 4."Which nursing assistants can I refer clients to?"

2."Which groups are at the greatest risk for problems?" Public health nursing is focused on improving the health status of the entire community. Although all the options are good to know, it is most important that the RN understands which groups in the community have the greatest health needs. Public health nurses collaborate with physicians, as well as with other health care providers, to assess and prioritize major health problems in the community. They also assist individuals and families to take action to improve their health status. Nursing assistants provide care for individual clients and families, but this question is more appropriate for a visiting or home health nurse

A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these approaches? 1.Inform the client that the hospital policy prohibits staff to date clients 2.Discuss the boundaries of a therapeutic relationship with the client 3.Tell the client that such behavior is inappropriate and unethical 4.Ask to not be assigned to this client or request to work on another unit

2.Discuss the boundaries of a therapeutic relationship with the client The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. The client may need to be educated about the interactions in a therapeutic relationship.

The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation? 1.Stay neutral and allow the staff nurse to handle this situation independently 2.Request an immediate private meeting with the health care provider and staff nurse 3.Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." 4.Notify the chief nursing officer about the breach of professional conduct

2.Request an immediate private meeting with the health care provider and staff nurse Assertive communication respects the needs of all parties to express themselves, but not at the expense of being in front of non-involved staff, visitors or clients. The nurse manager first needs to protect clients and other staff from this display of negative behavior and come to the assistance of the nurse employee. Privacy is a priority, as well as limiting the communication to only those involved.

A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first? 1.Viral pneumonia with atelectasis 2.Tension pneumothorax with slight tracheal deviation to the right 3.Acute asthma with episodes of bronchospasm 4.Spontaneous pneumothorax with a respiratory rate of 38

2.Tension pneumothorax with slight tracheal deviation to the right Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.

The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? 1.The nurse could be reprimanded for not clearing the information first with hospital administration 2.The nurse could be fired for breach of confidentiality 3.There won't be any consequences because the information was posted on a website for nursing professionals 4.There won't be any consequences because the client's real name was not used

2.The nurse could be fired for breach of confidentiality

A prison inmate is brought to the emergency department. The nurse overhears another employee speaking rudely to the inmate client. Acting as the client's advocate, the nurse tells the employee privately that all clients are to be treated with equal respect and dignity. Which client right has the nurse protected? 1. Free speech 2. Privacy 3. Considerate and respectful care 4. Confidentiality

3. Correct: Every client has the right to considerate and respectful care.

What resource should the nurse consult to determine the standards of care for an institution? 1. Organizational chart 2. Personnel policies 3. Policies and procedure manual 4. Job descriptions

3. Correct: It defines standards of care for an institution.

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse her load is too heavy and that she needs to reassign at least one of her clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of her clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN the reason she thinks her assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Correct: It would be best to explore the reason the RN thinks her assignment is too heavy. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed.

A rape victim is admitted to the emergency department for care. The police and primary healthcare provider insist that the client consent to a rape kit examination, but the client refuses. What should the nurse do? 1. Assist in the rape examination since this is a legal matter. 2. Isolate the client so she can think about her decision. 3. Respect the client's wishes. 4. Notify the closest relative who will influence the client to have exam.

3. Correct: The American Nurses' Association Code of Ethics for Nurses states: "The nurse's primary commitment is to the client, whether an individual, family, group or community."

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record can be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.

3. Correct: The client has the right to his medical record. Generally a period of time is required to get the record copied. The client may be charged for the copy.

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Try to convince the client to proceed with the plans for surgery. 2. Tell the client you will notify the surgery department to cancel immediately. 3. Tell the client that the primary healthcare provider will be notified immediately. 4. Suggest that the client talk over the decision with family members.

3. Correct: The client has the right to make decisions and to change his mind. The primary healthcare provider should be notified.

The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take? 1.Make a clinic appointment with the primary health provider for follow-up care the next day 2.Teach a family member clean dressing change technique and address safety measures in the home 3.Collaborate with the health care provider about the change of condition 4.Collaborate with the dietitian for increasing protein and calcium in the diet

3.Collaborate with the health care provider about the change of condition

A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager? 1.Confront the nurse about the suspicions in a private meeting 2.Schedule a staff conference, without the nurse present, to collect information 3.Consult with human resources personnel about the issue and needed actions 4.Counsel the employee to resign to avoid investigation and rumors

3.Consult with human resources personnel about the issue and needed actions The nurse manager needs to consult with human resources to determine the proper procedures for documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD by providing counseling and treatment for this disease.

A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? 1.Report of unstable angina with continuous telemetry monitoring 2.Tracheostomy of 24 hours with the client showing some respiratory distress 3.Pacemaker insertion on the day shift 4.Dopamine IV drip with vital signs monitored every five minutes

3.Pacemaker insertion on the day shift The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in critical care should not be assigned to the client with a newly created tracheostomy.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min; blood pressure 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138/min. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Correct: When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing.

A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse? 1.Assign the graduated staff nurse to be transferred to another floor for the shift 2.Provide an immediate one-on-one, personal in-service about the drain 3.Check with the nurse and the client often during the shift 4.Change the assignment; reassign the client with the lumbar drain to a different nurse

4.Change the assignment; reassign the client with the lumbar drain to a different nurse One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar drain.

The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next? 1.Administer the medication as ordered 2.Ask another staff nurse to discuss the same concerns with the hospitalist 3.Request a consult with the in-house pharmacist 4.Page the attending physician to express the same concerns

4.Page the attending physician to express the same concerns The scenario is an example of the "two-challenge rule." It is the nurse's responsibility to assertively voice concerns at least two times to ensure that it has been heard. If the outcome is still not acceptable, the nurse needs to take a stronger course of action by either contacting a supervisor or the attending physician to express the same concerns. The nurse must be an advocate for the client.

The triage nurse identifies that a 16 year-old client is legally married and has signed the consent form for treatment. What should be an appropriate action by the nurse? 1.Ask the teenager to wait until a parent or legal guardian can be contacted 2.Withhold treatment until telephone consent can be obtained from the partner 3.Refer the teenager to a community pediatric hospital emergency department 4.Proceed with the triage process in the same manner as any adult client

4.Proceed with the triage process in the same manner as any adult client Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.

A disoriented client is admitted to the med-surg unit with a diagnosis of acute renal failure. The client's spouse presents the nurse with an advance directive that gives instructions that no hemodialysis treatment is to be provided. What is the appropriate immediate action for the nurse to take at this time? 1. Inform the primary healthcare provider immediately of the advance directive and the client's wishes regarding no hemodialysis treatment. Place a copy of the advance directive in the client's medical record. 2. Obtain consent from the client's spouse for placement of the hemodialysis line and for acute hemodialysis. 3. Inform the client's spouse of the reason for the hemodialysis. 4. Tell the client's spouse to speak with the primary healthcare provider in order to make an informed decision on whether or not to proceed with hemodialysis.

1. Correct: The primary healthcare provider should be informed immediately if orders conflict with the client's wishes for treatment. A copy of the advance directive should always be placed in the client's medical record.

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. Correct: This client is at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm delivery. She is also receiving an oral tocolytic, terbutaline.

A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement? 1.The client has a right to know about the use and side effects of the prescribed medications 2.Such education is an independent decision of the individual nurse whether or not to teach clients about their medications 3.Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects 4.A referral is needed to the psychiatrist who should provide the client with answers to the request

1.The client has a right to know about the use and side effects of the prescribed medications Clients have a right to informed consent, which includes detailed information about medications, treatments and diagnostic studies. The other options are incorrect approaches

The nurse notices that the primary healthcare provider, who has been looking at his client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. The nurse should immediately log the primary healthcare provider off the facility's health information system. 2. The nurse should immediately minimize or hide the screen so that the client information is not longer visible, and then ask the primary healthcare provider if he will be returning to the computer work station. 3. The nurse should do nothing. The primary healthcare provider is a member of the health care team and is responsible for information accessed on the hospital's health information system. 4. The nurse should read the health information that the primary healthcare provider left visible on the computer screen to attempt to determine if the primary healthcare provider was finished.

2. Correct: It is appropriate and polite to minimize or hide the screen so that the information is no longer visible, then inquire whether the user will be returning to the computer work station.

Which statements should a nurse make when educating a client about advance directives? Select all that apply: 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding documents. 3. Will be placed in the client's medical record. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2., 3. & 4. Correct: Advance directives are legally binding documents which should be placed in the client's medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions.

The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first? 1.A 20 year-old in skeletal traction for two weeks since a motorcycle accident 2.A 72 year-old who returned from a right hip replacement surgery two hours ago 3.A 16 year-old who had an open reduction of a fractured wrist 10 hours ago 4.A 75 year-old who is in skin traction of the left leg prior to a scheduled fractured hip repair surgery

2.A 72 year-old who returned from a right hip replacement surgery two hours ago The nurse should compare clients to screen for one who has the most imminent risks and acute vulnerability for being unstable. The client who returned from surgery two hours ago is at risk for hemorrhage because the hip and femur are considered vascular areas and should be checked first. The 16 year-old is within the initial 24 hours post-op period and should be seen next. The 75 year-old is potentially vulnerable to age-related physical and cognitive impairments from being on bedrest and having a large bone fracture. The client who can safely be visited last is the 20 year-old who is two weeks post-injury.

The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by his employer and his spouse. What is the best rationale for including assertiveness training in this client's treatment plan? 1. All clients should have assertiveness skills. 2. The client has low self-esteem. 3. The client is being taught self-advocacy. 4. No client deserves to be manipulated by an employer.

3. Correct: The client is being taught self-advocacy. The nursing role includes advocacy. This client will be discharged soon and needs improved skills for advocating for himself.

A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects assertive communication? 1."I am having difficulty reading your handwriting. It would save me time if you would be more careful." 2."Please print in the future so I do not have to spend extra time attempting to read your writing." 3."Would you please clarify what you have written so I am sure I am reading it correctly?" 4."I cannot give this medication as it is written. I have no idea of what you mean."

3."Would you please clarify what you have written so I am sure I am reading it correctly?" Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? 1.Report to the nurse manager about the witnessed suspicious activity 2.Immediately call security for this breach in client confidentiality 3.Request to see identification and an explanation as to why the woman is viewing client charts 4.Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care

3.Request to see identification and an explanation as to why the woman is viewing client charts Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation.

Which sign/symptom of hypoxemia in a client with pneumonia is most important for the nurse to report to the primary healthcare provider? 1. Radial pulse of 98 2. Arterial blood gas Pa02 of 96 3. Fatigue 4. Confusion

4. Correct: A more acute sign of hypoxemia is a change in the client's level of consciousness. Confusion is one of the acute signs of decreased arterial oxygen in the blood.

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)

4. Correct: A temperature of 100.5 ° F (38.05 ° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies.

The nurse is entering data in the electronic medical record. The computer terminal is located on a rolling cart in the hallway. Which action by the nurse is most likely to result in a possible breach of confidentiality of medical records? 1. Entering the data on assigned client. 2. Recording the client history of an abortion. 3. Checking lab results. 4. Failing to log out of the terminal before walking away.

4. Correct: Failing to log out may allow persons not concerned with the care of the client to access private information.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative floor. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on her clients. 3. The nurse's role includes assessment of vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated.