NUR 212 test 2 new

Question 1 A new nurse aware of Hospital Core Measures is assessing a diabetic client admitted with a BNP level of 1,500 pg/mL. The client is complaining of weakness, nausea and a loss of appetite. What action should the nurse take first? Select one: 1. Check the client's vital signs. 2. Make a referral to the Dietician for menu planning 3. Provide discharge CH instructions to the wife. 4. Suggest the client rest before eating any meals

'1 The correct answer is: Check the client's vital signs.

Question 69 The nurse is aware that according to the "Surgical Care Infection Prevention" (SCIP) quality care measures the best way to prevent post-operative wound infection in the surgical client is to: Select one: 1. Wash hands for at least two minutes before providing care. 2. Stop prophylactic antibiotics within 12 hours after surgery. 3. Advocate for prophylactic DVT (deep vein thrombosis) interventions 2-days postoperatively. 4. Ask the client to wear a mask or cover their mouth when she coughs.

1 Answer is correct. The number one way to prevent the spread of infections is hand hygiene. The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection, not prevent infections, making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore, answers C and D are incorrect.

Question 14 The nurse working in the outpatient clinic anticipates the provider to request, which lab test for a patient with a complaint of right abdominal pain and a low-grade temperature? Select one: 1. White blood cell count 2. Platelet count 3. Hemoglobin and hematocrit 4. Serum albumin level 5. Hemoglobin A1C

1 Answer: White blood cell count - Correct Rationale: Since the appendix is a small, pouch-like sac of tissue that is located in the first part of the colon (cecum) in the lower-right abdomen, the patient may be experiencing appendicitis. The other labs are unrelated. The correct answer is: White blood cell count

Question 74 The new nurse must follow medication administration guidelines when administering high alert medications. In this case, a cardiac client has a prescription for heparin sodium 7,000 units IV. The vial contains 10,000 units/ mI. How many milliliters of heparin should the nurse administer and using what type of syringe/needle? Select one: o 1. 0.7 ml using a 1 ml syringe and 25G needle o 2. 1.0 ml using a 1.0 ml syringe and 25G needle o 3. 0.3 ml using a 3 ml syringe and 25G needle o 4. 0.7 ml using a 3 ml syringe and 25G needle o 5. 0.3 ml using a 1 ml syringe and 20G needle

1 Dosage Calculation The correct answer is: 0.7 ml using a 1 ml syringe and 25G needle

Question 7 In the role as the hospital infection control nurse, which quality improvement process should be implemented to most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? Select one: 1. Set a goal to limit the use of indwelling urinary catheters in all hospitalized clients. 2. Require the use of antimicrobial/antiseptic impregnated catheters for catheterization. 3. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 4. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria.

1 Focus: Prioritization The correct answer is: Set a goal to limit the use of indwelling urinary catheters in all hospitalized clients.

Question 35 After receiving a SBAR report on the evening shift, which client should he nurse attend to first? Select one: 1. A 34 yo. man with non-Hodgkin Lymphoma and a serum K+ of 7.9 mEg/L. 2. A 55 yo. client with ovarian cancer waiting for discharge. 3. A 21 yo. woman with sickle-cell anemia and a c/o pain at 3/10. 4. A 72 yo. man with COPD and a pulse oximetry trending from 92% to 94%.

1 Hyperkalemia is a serious complication and could lead to severe bradycardia. In a patient with non-Hodgkin Lymphoma it could indicate lysis of the tumor

Question 16 A nurse is completing discharge paperwork for a patient admitted with a BNP of 1,300 pg/mL. After reviewing the med reconciliation and core measures checklists, the nurse notes that the patient has been prescribed Lasix, Losartan, and Propranolol. What action should the nurse take next? Select one: 1.Check the chart for documentation as to why an ACEI was not prescribed 2.Document in the medical record an ACE and ARB were not prescribed 3.Notify the physician the prescription does not include an ARB 4.Notify the physician the prescription does not include an ACEI 5.Continue with the discharge without question

1 Medication Reconciliation - Should review the chart to determine the consideration or contradiction of an ACE and ARB. Then the nurse would contact the provider for clarification. The correct answer is: Check the chart for documentation as to why an ACE was not prescribed

Question 40 The nurse is discussing follow-up care with a client who is being discharged. The client and family cross their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is appropriate? Select one: 1. "Let's discuss the options you believe may work for you and your family." 2. "Perhaps you did not understand the options you were given." 3. "We will leave you alone as a family to discuss your options." 4. "The team only suggested what was best for you."

1 The client is the center of the team, and the goal is to facilitate healing. There are always other options to consider to reach that goal. The nurse would discuss other options with the client, which will most likely increase cooperation by the client, who will feel in control as the decision is made. By leaving the room, the nurse and doctor have turned their backs on the client. The client may not understand the recommendations, but pointing that out can be seen as demeaning. Telling the client that the doctor only wants what is best sends the message that the client does not know what is best, when, in fact, a well-informed client does know what is best and should be able to make the correct choice. The correct answer is: "Let's discuss the options you believe may work for you and your family."

Question 49 A nurse is conducting a medication reconciliation for a client who is newly admitted to the facility. Which of the following actions should the nurse take first? Select one: 1. Assess which over-the-counter medications are taken by asking the client. 2. Collaborate with the pharmacist to review the medication list. 3. Ask the LP/LVN to reinforce medication teaching with the client. 4. Investigate discrepancies in medication administration record.

1 The correct answer is: Assess which over-the-counter medications are taken by asking the client. When using the nursing process, the first action the nurse should take is to assess the client by completing a comprehensive review of prescribed and over-the-counter medications, as well as herbal and nutritional supplements the client takes. The nurse should obtain a comprehensive list in order to identify duplication as well as any possible contraindications or interactions between medications

Question 42 A nurse is admitting a client with community-acquired pneumonia on test (PNA) really (CAP) and an elevated core body temperature. The nurse is reviewing the PNA core measures and should identify which of the following medications as the priority to administer? Select one: 1. Clarithromycin 2. The intravenous crystalloid solution 3. Acetaminophen 4. Guaifenesin 5. Dextromethorphan

1 The correct answer is: Clarithromycin The client who presents with pneumonia should receive antibiotic treatment within the first 6 hr of admission. This limits complications such as sepsis and mortality. The greatest risk to this client is injury from infection. Therefore, the priority medication for the nurse to administer is the clarithromycin.

Question 13 The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L. On the basis of this laboratory result, which "interdependent" intervention should the nurse include in the plan of care, first? Select one: 1. Initiate bleeding precautions. 2. Initiate contact precautions. 3. Monitor the temperature every 4 hours. 4. Monitor closely for signs of infection. 5. Initiate protective isolation or neutropenic precautions.

1 The correct answer is: Initiate bleeding precautions. Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding.

Question 65 A nurse manager reviewing the NDNQI falls rate indicator, assesses the unit environment in order to decrease the risk for client falls. Which is the best intervention for the manager to suggest to decrease the risk of falls for clients? Select one: 1. Keep the bed low and the care environment clear of clutter. 2. Keep the call button within reach at all times. 3. Read labels before administering psychotropic medications. 4. Keep electrical cords on the right side of the bed.

1 The correct answer is: Keep the bed low and the care environment clear of clutter. Keeping the environment tidy and free of clutter will go a long way in preventing falls. The call button should always be within reach of the client, but is not the best way to prevent falls. Electrical cords should be used only if necessary, and the maintenance department can help if any of them present a hazard. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls. Keeping the bed low and the environment tidy/free of clutter will go a long way in preventing falls. The call button should always be within reach of the client, but is not the best way to prevent falls. Electrical cords should be used only if necessary, and the maintenance department can help if any of them present a hazard. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls

Question 45 A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After applying soft hand restraints to protect the client's airway, which action should the nurse take next? Select one: 1. Notify the primary provider within one hour. 2. Notify the family of the need for restraints. 3. Reassess the need for the restraints in 8 hours. 4. Document the application of restraints in the chart.

1 The correct answer is: Notify the primary provider within one hour. According to the law, the primary healthcare provider must see the client and write a prescription for restraints within 1 hour of application. The nurse would apply the restraints to protect the airway and then immediately notify the primary healthcare provider. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.

Question 67 A client who sustained a traumatic brain injury several weeks ago is in a chronic vegetative state and is no longer competent to make healthcare decisions. Who should the nurse expect to make care decisions for this client? Select one: 1. The agent named in the durable power of attorney 2. The physician 3. The client's spouse 4. Social services

1 The nurse, recognizing that the client is no longer competent, should follow whatever hospital policy is in place for contacting the agent named in a durable power of attorney for healthcare. The physician is not the appropriate individual to make decisions for the client. Social services may be the department that would contact the agent of a durable power of attorney, but social services would not be that power. In the case of an incompetent client, the spouse would be the agent of the durable power of attorney only if the court appointed the spouse. Page Ref: 2843 Concepts Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care The correct answer is: The agent named in the durable power of attorney

Question 17 A client with terminal cancer has signed an advance directive indicating that no parenteral nutrition or hydration will be implemented. For several days the client has refused food and fluids, pushing the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." Which actions by the nurse are appropriate? Select all that apply. 1. Honor the client's refusal of parenteral nutrition and hydration. 2. Help the family come to terms with the situation. 3. Talk to the healthcare provider so the family's wishes can be acted upon. 4. Take the case to the hospital's ethics committee. 5. Honor the family's wishes and have them sign a consent form.

1 2 A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. This position is supported by the ANA's Code of Ethics for Nurses, through the nurse's role as a client advocate and through the moral principle of autonomy. Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client's refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.

Question 31 A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) Select one or more: 1. The date of the incident 2. The client's vital signs 3. The time the client was to receive the medication 4. The "potential' adverse or long-term effects of the medication

1 2 3 Answer Rationale: The date of the incident is correct. When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date The name of the provider who prescribed the medication is incorrect. The nurse does not need to include the name of the provider who prescribed the medication as this information is part of the client's medical record. The potential adverse and-long term effects of the medication are incorrect. The nurse should only include factual information about the incident and not potential effects. The time the client was to receive the medication is correct. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication. The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report.

Question 28 An older adult client with metastasized breast cancer informs the nurse that her doctor is insisting that she participate in a course of chemotherapy, even though the client does not want to have any further treatment. Which actions by the nurse exemplify advocacy for this client? Select all that apply. 1. Inform the doctor about the client's clear wishes not to have further chemotherapy. 2. Avoid interfering in the doctor-client relationship. 3. Tell the client that it is in her best interest to follow the doctor's advice. 4. Discuss the implications of various choices with the client. 5. Ascertain whether or not the client has an advance care directive and, if not, assist her in creating one.

1 4 5 Nurses acting as advocates should honor the moral principles and standards and respect clients' right to make their own choices. The nurse should continuously advocate for the client in a professional manner. The nurse serves as both a teacher and an advocate by informing clients about their rights. When the client makes decisions about his or her treatment other than what is recommended, it is the nurse's role to ensure that the client is making an informed decision and, if so, to advocate for the client's right to make autonomous choices Page Ref: 2721 Concepts Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care The correct answers are: Inform the doctor about the client's clear wishes not to have further chemotherapy., Ascertain whether or not the client has an advance care directive and, if not, assist her in creating one., Discuss the implications of various choices with the client.

Question 27 The RN, LP and UAP should be assigned to which patients to provide safe care? (Each role may be used more than once). 1.A 59 yo. client with DM Type II requiring 2 units of Humulog (Lispo) insulin SQ. 2.A 72 yo. renal patient prescribed hydralazine PO with a BP 150/90 mg/Hg 3.A 79 yo. returning from dialysis w/ Hgb of 7.0 and one (1) unit of blood prescribed. 4.A 52 yo. alcoholic patient with cirrhosis and pancreatitis asking for the urinal. 5.A 69 yo. nursing home resident being admitted for urosepsis and AMS changes. 6.A 36 yo. patient with an established tracheostomy and a speaking valve asking to turn and position.

1. LPN 2. LPN 3. RN 4. UAP 5. RN 6. UAP

Question 79 The LP/LVN whom you are supervising comes to you and says, "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions? A. Complete a medication error report. B. Ask the LPN/LVN to explain how the error occurred C. Place the client on a telemetry monitor. D. Notify the physician of the incorrect medication dose. E. Assess the client's heart rate.

12345 A. 5 B. 4 C. 2 D. 3 E. 1

Question 63 To prevent a CAUTI, the nurse questions if the Foley should be discontinued. The health team determines it is best to discontinue a patient's Foley catheter. Which nursing actions should the nurse? (Select All That Apply) Select one or more: 1. Ask the experienced RN to evaluate an attempt at bladder training before the catheter is removed. 2. Ask the new RN to assess the client's urinary output for the previous shift. 3. Instruct the experienced UAP to discontinue the catheter and measure the output. 4. Ask the LPN to explain the potential of urgency after the Foley is removed. 5. Instruct the UAP to ambulate the patient to the bathroom during rounds. During rounds, the nurse questions if the Foley should be discontinued. The health team determines it is best to discontinue a patient's Foley catheter. Which nursing actions should the nurse take? (Select All That Apply) Select one or more: a. Ask the UAP to unclamp the catheter after repeated attempts at bladder training. b. Discuss the potential need for urgency immediately after the foley is removed. c. Assess the client's urinary output for the previous hour. d. Instruct the UAP to ambulate the patient to the bathroom bef

12345 ALL ANSWER - A,B,C, E The correct answers are: Ask the experienced RN to evaluate an attempt at bladder training before the catheter is removed., Ask the LP to explain the potential of urgency after the Foley is removed., Ask the new RN to assess the client's urinary output for the previous shift., Instruct the UAP to ambulate the patient to the bathroom during rounds., Instruct the experienced UP to discontinue the catheter and measure the output.

Question 80 The RN is the leader of a team providing care to six clients. The "skill mix" includes the RN, an experienced LP and a new UP who has completed four weeks of orientation. Which clients should the RN plan to assess first at the beginning of the shift? (Put all patients in order) A. A 59 yo. client with a history of COPD and mild shortness of breath. B. An 83 yo. female patient with a past medical history of heart disease, a myocardial infarction and dementia. C. A 45 yo. diabetic female who had chest pain at 1 of 10 during the night and continues to complain of chest pressure D. A 93 yo. newly admitted client with altered mental status, a temperature of 99.5 F (37.5 C), an apical pulse of 106, foul smelling urine and urine output <0.5 mi/kg/hr. E. A 75 yo. male with a left hemisphere, ischemic stroke 5 days prior. F. A 68 yo. patient with a history of angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning.

123456 A. 3 B. 4 C. 1 D. 2 E. 5 F. 6 Case Study 1. Ms. J- active chest pain 2. Mr. B - Sepsis 3. Mr. L - Mild SOB 4. Ms. S - Old MI and Dementia 5. Mr. R - Stroke 4 days ago 6. Mr. C - Reinforcing teaching - Last because no acute problems The correct answer is: A 59 yo. client with a history of COPD and mild shortness of breath. Third An 83 yo. female patient with a past medical history of heart disease, a myocardial infarction and dementia. Fourth A 45 yo. diabetic female who had chest pain at 1 of 10 during the night and continues to complain of chest pressure. First A 93 yo. newly admitted client with altered mental status, a temperature of 99.5 F (37.5 C), an apical pulse of 106, foul smelling urine and urine output <0.5 ml/kg/hr. Second A 75 yo. male with a left hemisphere, ischemic stroke 5 days prior. Fifth A 68 yo. patient with a history of angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning. Sixth

Question 72 According to the Institute of Healthcare Improvement, over 100,000 deaths occur as a result of in-hospital errors and more than 50% are preventable. Which of the following are client safety issues that could be prevented or should never occur in healthcare? (Select All That Apply) Select one or more: 1. Death or serious injury associated with a metallic object into the MRI area. 2. A stage 3, stage 4, or unstageable pressure injury acquired after admission. 3. Discharge of a patient of any age, who is unable to make decisions about their care. 4. Patient death or serious injury associated with a fall. 5. Patient death or serious injury associated with intravascular air embolism. 6. Patient death or serious disability associated with an Alzheimer's patient elopement. 7. Patient death or serious injury associated with the use of restraint or bedrail. Which of the following are client safety issues could be prevented or should never occur in healthcare? (Select All That Apply) Select one or more: a. Death or serious injury associated with a metallic object into the MRI area. b. Discharge of a patient of any age, who is unable to make decisions. c.Patient death or serious injury

1234567 ALL According to the Institute of Healthcare Improvement, over 100,000 deaths occur as a result of in hospital errors and more than 50% are preventable. ALL Never Events https://psnet.ahrg.gov/primers/primer/3/never-events The correct answers are: Patient death or serious injury associated with a fall., Death or serious injury associated with a metallic object into the MRI area., Patient death or serious disability associated with an Alzheimer's patient elopement., Discharge of a patient of any age, who is unable to make decisions about their care., Patient death or serious injury associated with the use of restraint or bedrail., Patient death or serious injury associated with intravascular air embolism., A stage 3, stage 4, or unstageable pressure injury acquired after admission.

Question 62 To promote a just culture, the nurse manager is explaining transparency and the use of incident reports to a group of nurses. Which of the following statements should the nurse manager include? (Select all that apply) Select one or more: 1. Incident reports include a description of the incident and the actions taken. 2. Incident reports should not be shared with the client. 3. A description of the incident should be documented in the client's health care record. 4. A copy of the incident report should be placed in the client's record. 5. The risk management department will investigates the incident. A nurse manager is explaining transparency and the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? (Select all that apply) Select one or more: a. Incident reports include a description of the incident and the actions taken. b. A copy of the incident report should be placed in the client's record. c. A description of the incident should be documented in the client's health care record. d. Incident reports should not be shared with the client. e. The risk management department investigates t

1235 ACDE The correct answers are: A description of the incident should be documented in the client's health care record., Incident reports should not be shared with the client., Incident reports include a description of the incident and the actions taken., The risk management department will investigates the incident. Incident reports include a description of the incident and the actions taken. Correct, accurate description and actions taken. A description of the incident should be documented in the client's health care record. Correct, factual description of the event The risk management department will investigates the incident.Correct: Risk managers investigate all incidents as part of the agency's quality assurance program.

Question 53 At the beginning of the shift, the nurse completes a fall risk assessment for a 78 yo. client admitted with heart failure. Considering the nurse-sensitive indicators (NDNQI), it is determined the client is at a high risk for falls. Which patient safety interventions should the nurse implement specifically to prevent the risk of falls? (Select All That Apply) Select one or more: 1. Instruct client about the effects of diuretics 2. Obtain the client's vital signs every shift 3. Conduct rounds hourly 4. Assist the client to the bathroom before administering the diuretic 5. Anticipate bladder needs and initiate bladder training 6. Request an order for prn restraints

1345 The nurse completes a Morse fall risk assessment for a 68 yo. client admitted with a right foot pressure injury at the beginning of the shift. It is determined the client is at a high risk for falls. Which patient safety or "anticipatory guidance" interventions should the nurse implement to prevent the risk for falls? (Select All That Apply) Anticipatory Guidance/Excellent Care - Assist the client to the bathroom before administering the diuretic. The correct answers are: Instruct client about the effects of diuretics, Conduct rounds hourly, Anticipate bladder needs and initiate bladder training, Assist the client to the bathroom before administering the diuretic

Question 50 After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are appropriate in this situation? Select all that apply. 1. Telling the client that changes to the advance directive can be made at any time 2. Telling the client that it is not necessary to make decisions about healthcare needs in the future 3. Giving a copy of the advance directives to the client's adult children 4. Having the client name an individual to be responsible for care decisions 5. Educating the client about the purpose and types of life-sustaining measures

135 The nurse should explain that if a decision is made on an advance directive, the decision can be changed. Clients should be instructed to provide a copy of their advance directives to their next of kin. The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures and provide teaching on these measures if necessary. An advance directive does not mean that the client does not need to make any future decisions about healthcare. An individual to be responsible for care decisions is a durable power of attorney for healthcare and may or may not be included when creating an advance directive. Concepts p. 2844 The correct answers are: Telling the client that changes to the advance directive can be made at any time, Giving a copy of the advance directives to the client's adult children, Educating the client about the purpose and types of life-sustaining measures

Question 60 A nurse is serving on a quality improvement (QI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? Select one: 1. Develop a quality improvement program for nurses involved in medication administration errors. 2. Review the events leading up to each medication administration error. 3. Require staff nurses to demonstrate competency by passing a medication administration examination. 4. Provide an inservice on medication administration to all the nurses. A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? 1. Provide an inservice on medication administration to all the nurses. 2. Require staff nurses to demonstrate competency by passing a medication administration examination. 3. Review the events leading up to each medication administration error. 4. Develop

2 ANSWER - 3 Rationale: After a sentinel event, the first step the committee should plan to take is to use root cause analysis to identify the underlying cause or causes that led to the medication errors. The correct answer is: Review the events leading up to each medication administration error.

Question 20 A nurse is assisting with the selection of clients to discharge to make beds available following a hurricane in the community. Prioritize the clients in the order the nurse should recommend for discharge? 1. An 80 yo. client admitted 24 hrs ago for fluid volume deficit and a potassium level of 3.0 mEq/L 2. A 28 yo. client who is recovering from a laparoscopy appendectomy performed 24 hours ago 3. A 56 y.o client with uterine cancer and intracavity placement of radiation 3 days ago 4. A 67 v.o. client with a sodium level of 146 mE/L, being re-hydrated with 2000 mL of normal saline for heat stroke. Select one: 1. 4, 2, 3, 1 2. 2, 3, 4, 1 3. 2, 4, 3, 1 4. 2, 1, 3, 4 5. 4, 2, 3, 1

2 Safe and Effective Care A nurse is assisting with the selection of clients to discharge to make beds available following a hurricane in the community. Which of the following clients should the nurse recommend for discharge? 1. A client who was admitted 24 hours ago for fluid volume deficit and now has a potassium of 3.1 mEq/L 2. A client who is recovering from a laparoscopy appendectomy that was performed 24 hours ago 3. A client who has uterine cancer and had intracavity placement of radiation 30 hours ago 4. A client who was admitted to the hospital 12 hours ago for heat stroke and has been rehydrated with 2000mL of normal saline Rationale: B. Clients who have had an appendectomy without complications are usually discharged either the day of surgery or the day after surgery. Therefore, the nurse should recommend the client for discharge. The correct answer is: 2, 3, 4,1

Question 4 The nurse is planning to carry out advocacy interventions when caring for a client with brain cancer. Which value should the nurse recognize as most basic to client advocacy? Select one: 1. The client is a dependent being who has the right to expect the nurse to solve all healthcare needs. 2. The client is a holistic, autonomous being who has the right to make choices and decisions. 3. Clients should be advised that making their own care decisions is almost invariably detrimental to their well-being. 4. The nurse has the responsibility to ensure the client's decisions guide care regardless of whether the client is mentally competent.

2 Safeguarding clients' autonomy is the first core attribute of advocacy. It requires respecting and promoting each client's right to self-determination, except in those situations when the client is incompetent to decide or does not wish to be involved in decision making. Clients should not be discouraged from making their own decisions or be treated as naturally dependent.

Question 55 A client being treated with sodium warfarin has a Pro-time (PT) of 120 seconds. Which quality care action would be most important to include in the nursing plan of care? Select the BEST Answer Select one: 1. Increase the frequency of neurological assessments. 2. Assess for signs of abnormal bleeding. 3. Prepare to administer protamine sulfate. 4. Anticipate an increase in the Coumadin dosage. 5. Instruct the client regarding the importance of the drug therapy.

2 The correct answer is: Assess for signs of abnormal bleeding. Answer A is correct. The normal Pro-time is approximately 12-20 seconds. A Pro-time of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.

Question 43 A nurse discovers that a client was administered an antihypertensive medication in error. Number the following actions in the appropriate sequence that the nurse should follow. A.Call the client's provider. B.Monitor the client's vital signs C.Notify the Risk Manager D.Complete an incident report E.Instruct the client to remain in bed until further notice. Select one: 1. E, B, A, C, D 2. B, E, A, D, C 3. A, B, E, D, C 4. E, A, B, D, C

2 The correct answer is: B, E, A, D, C

Question 25 The client's mother contacts the clinic regarding safe medication administration. She states, "My daughter can't swallow this capsule. It's too large." Investigation reveals that the medication is a capsule marked SR (sustained release). Therefore, the nurse should instruct the mother to: Select one: 1. Open the capsule and mix the medication with ice cream. 2. Consult the pharmacist for an alternative suggestion. 3. Crush the medication and administer it with 8 oz. of liquid. 4. Stop the medication and inform the physician at the follow-up visit.

2 The correct answer is: Consult the pharmacist for an alternative suggestion. SR means sustained release. These medications cannot be altered.

Question 30 The preceptor has prioritized various care tasks on the new nurse's checklist. For the newly admitted Gl client who is to receive continuous tube feeding (TF), which quality care action should be listed on the checklist? Select one: 1. Allowing the TF to run dry before the bag is filled. 2. Filling the TF container with enough supplement to prevent running dry. 3. Instructing the UAP to keep the client's head flat. 4. Clamping the TF every hour. ORIGINAL QUESTION Continuous Tube Feeding 1. Filling the feeding bag. Turn the pump to STOP/OFF. Close the clamp on the feeding bag tubing. 2. Filling the TF container with enough supplement to last 6-8 hours. 3. Connecting the feeding bag. Put the feeding bag tubing through the front of the pump. Connect the feeding bag tubing to the feeding tube port. 4. Turning on the pump. Check that the settings on the pump are correct.

2 The correct answer is: Filling the TF container with enough supplement to prevent running dry.

Question 24 The health care provider has written the following orders for a dialysis client with a diagnosis of Heart Failure. The client's assessment reveals a trending BP of 177/89, JD, bounding pulses at 4+, oxygen saturation of 92%, a productive cough, and moist crackles bilaterally. Which interventions would the prudent (competent) nurse complete in order of priority? 1. Evaluate the client's vital sign trends. 2. Remind the patient to restrict the intake of PO fluids. 3. Contact the dialysis nurse to schedule the best time for treatment. 4. Administer the Hydrochlorothiazide as prescribed. 5. Ask the therapist to initiate Bipap after the breathing treatment. 6. Update the provider with the client's status. Select one: 1. 1, 4, 3, 2, 5, 6 2. 4, 5, 2, 3, 1, 6 3. 1, 4, 3, 5, 2, 6 4. 4, 5, 1, 3, 2, 6 5. 4, 6, 5, 2, 3, 1

2 The health care provider has written the following orders for a dialysis client with a diagnosis of Heart Failure. The client's assessment reveals a trending BP of 177/89, JD, bounding pulses at 4+, oxygen saturation of 92%, a productive cough, and moist crackles bilaterally. Which interventions would the prudent (competent) nurse complete in order of priority? 1. Evaluate the client's vital sign trends. 2. Remind the patient to restrict the intake of PO fluids. 3. Contact the dialysis nurse to schedule the best time for treatment. 4. Administer the Hydrochlorothiazide as prescribed. 5. Ask the therapist to initiate Bipap after the breathing treatment. 6. Update the provider with the client's status. Correct Answer 4, 5, 2, 3, 1, 6 The correct answer is: 4, 5, 2, 3, 1, 6

Question 33 The RN in the long-term care settings asks a skilled UAP to assist a resident with performing a simple dressing change. The resident was formerly able to do the procedure, but because of painful arthritis is now unable to perform the redressing. The UAP has assisted the client before. What must the nurse emphasize to the UAP? Select one: 1. Instruct the resident to do most of the simple dressing change procedure. 2. Stop the procedure immediately and report anything unusual, such as bleeding. 3. Provide instructions to the resident's family while performing the dressing change. 4. Assess the resident's return-demonstrate of the procedure.

2 The nurse delegated a specific legal task to the UAP, which is within the scope of the UP's ability. The nurse established the particular parameters outside of which immediate notification is requested. If in pain, the client should not have to do any of the procedure. If the UP has done the procedure before, the nurse should not need to demonstrate it. Health teaching is outside of the scope of practice for the UAP. The correct answer is: Stop the procedure immediately and report anything unusual, such as bleeding.

Question 70 By providing volunteer client care to an inadequately insured population, the nurse is demonstrating which value of client advocacy? Select one: 1. The nurse has the responsibility to make choices and decisions. 2. The nurse has the responsibility to ensure the client has access to healthcare services. 3. The client has the right to expect a nurse-client relationship based on shared respect. 4. The client has the right to make choices and decisions.

2 The nurse has the responsibility to ensure the client has access to healthcare services that meet health needs. Although the client does have the right to make choices and decisions, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. Although the client does have the right to expect a nurse-client relationship based on shared respect, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. The nurse's responsibility to make choices and decisions is not one of the values basic to client advocacy. Page Ref: 2719, 2720 Concepts Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance The correct answer is: The nurse has the responsibility to ensure the client has access to healthcare services.

Question 19 The nurse has been working in a long-term care facility for 1 week. The nurse notes that during the evening meal, an UAP gives a tray to a client who is unable to cut up and eat the food independently, and then leaves. After the nurse assists the client with eating the meal, which action is appropriate to advocate for this client? Select one: 1. Call the client's family to have them assist with evening meals. 2. Discuss the situation with the director of nursing. 3. Notify the healthcare provider. 4. Report the UAP for neglect.

2 The nurse would advocate getting the client's plan changed because the goal is to have someone available to help the client eat for every meal. Notifying the doctor will not help the client. The family might be able to help at times but cannot be expected to come for every meal. The nurse assesses that this happens at every meal and seeks to change how this client is cared for, not just changing one healthcare worker. The UAP is not neglecting the client. The UAP is assigned tasks by the nurse in charge of the client. Page Ref: 2723 Concepts

Question 41 The charge nurse is making assignments for a nursing team that consists of an experienced RN, LP/LVN, and UAP. Which patients should be "appropriately" assigned to the RN? (Select All That Apply) Select one or more: SATA 1. A 23-year-old patient with a fracture of the right leg who asks to use the urinal. 2. A 42-year-old patient with cancer of the bone complaining of pain. 3. A 55-year-old patient with terminal cancer being transferred to hospice home care. 4. A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. The charge nurse is making assignments for a nursing team that consists of the RN, LP/LVN, and UP. Which patients should be assigned to the RN? (Select All That Apply) A nursing team consists of an RN, an LP/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? 1. A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. 2. A 42-year-old patient with cancer of the bone complaining of pain. 3. A 55-year-old patient with terminal cancer being transferred to hospice home care. 4. A 23-year-old patient with a fracture of the right leg who asks to use the urinal

2 3 Safe and Effective Care Environment 1 Rationale: A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer.-question: which patient is an appropriate assignment for the Ip/Ivn? strategy: think about the skill level involved in each patients care. needed info: Ipn/Ivn: assists with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications (varies with educational background and state nurse practice act). (a) a 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer correct: stable patient with an expected outcome (b) a 42-year-old patient with cancer of the bone complaining of pain requires assessment; rn is the appropriate caregiver (c) a 55-year-old patient with terminal cancer being transferred to hospice home care requires nursing judgement; rn is the appropriate caregiver (d) a 23-year-old patient with a fracture of the right leg who asks to use the urinal standard unchanging procedure; assign to the nursing assistant The correct answers are: A 42-year-old patient with cancer of the bone complaining of pain., A 55-year-old patient with terminal cancer being transferred to hospice home care.

Question 34 A precepting nurse is teaching a new nurse about Scope of Practice and nurse sensitive indicators. Which is an example of a caring intervention related to Scope of Practice and the identified NDNQI nurse sensitive indicators? Select All That Apply. selecrone or more: 1. Discontinuing the prophylactic antibiotic within 48-72 hours after surgery 2. Hand hygiene to prevent CLI (central line infections) 3. Revising policies to prevent peripheral IV infiltrations. 4. Turning and re-positing a client Q2H after a wound debridement. A precepting nurse is teaching a new nurse about Scope of Practice and nurse sensitive indicators. Which is an example of a caring intervention related to Scope of Practice and the identified NDNQI nurse sensitive indicators? Select All That Apply. (No partial credit) Select one or more: a. Turning and re-positing a client Q2H after a wound debridement. b. Hand hygiene to prevent CLI (central line infections) c. Reviewing and revising policies to prevent peripheral IV infiltrations. d. Discontinuing the prophylactic antibiotic within 24 hours after surgery

2 3 4 Answer: Nurse Sensitive Indicators A B C The correct answers are: Turning and re-positing a client Q2H after a wound debridement., Hand hygiene to prevent CLI (central line infections), Revising policies to prevent peripheral IV infiltrations.

Question 18 A nurse who has just assumed the role of unit manager is examining the skills necessary for interprofessional collaboration. Which of the following actions support the nurse's interprofessional collaboration? Select all that apply. 1. Use aggressive communication when addressing the team. 2. Support team member requests for referral. 3. Ensure that a nurse is assigned to serve as the group facilitator for all interprofessional meetings. 4. Encourage the client and family to participate in the team meeting. 5. Recognize the knowledge and skills of each member of the team.

2 4 5 The nurse should use assertive skills when communicating with the interprofessional team. The nurse should recognize that each member of the team has specific skills to contribute to the collaboration process. A nurse can serve as the facilitator. However, this role can be assumed by any member of the team. Collaboration should occur among the client, family and interprofessional team. The nurse should support suggestions for referrals to link clients to appropriate resources. Leadership ATI p. 31 The correct answers are: Recognize the knowledge and skills of each member of the team., Encourage the client and family to participate in the team meeting., Support team member requests for referral.

Question 64 The staff nurse is leading an in-service orientation program regarding informed consents. Which of these statements indicates the nurse understands the manner for obtaining these consents? Select all that apply. 1. "The client's spouse must be present during the process of signing the informed consent." 2. "The information discussed with the client prior to the signature will be adequately disclosed." 3. "The client was informed clearly of the risks involved with the procedure, surgery, etc., and verbalized this understanding prior to signing the consent." 4. "The client indicates a voluntary consent with this signature." 5. "The nurse will assess knowledge level of the surgical procedure and answer any questions the client may have."

234 Client should have an understanding of the risks involved prior to signing Requiring the spouse to be present is not a standard of care. Answering any questions the client has is not within the scope of practice of the nurse. The correct answers are: "The client indicates a voluntary consent with this signature." "The information discussed with the client prior to the signature will be adequately disclosed." "The client was informed clearly of the risks involved with the procedure, surgery, etc., and verbalized this understanding prior to signing the consent."

Question 44 Each novice nurse must become more aware of their role in preventing "Failure to Rescue" events. Which strategies or interventions should the nurse employ to prevent failure to rescue? (Select All That Apply) Select one or more: 1. Document agreement with the previous nursing assessment. 2. Use SBAR to communicate patient status changes immediately. 3. Use checklists and standards to ensure quality care is provided 4. Activate the rapid response team (RT) with significant changes in condition. 5. Know and use the chain of command to get the needed resources or response. Each novice nurse must become more aware of their role in preventing "Failure to Rescue" events. Which strategies or interventions should the nurse employ to prevent failure to rescue? (Select All That Apply) Select one or more: ANSWER - A,B,C,E a. Use SBAR to communicate patient status changes immediately. b. Use checklists, standards and guidelines to ensure quality care is provided to "every patient every time." c. Activate the rapid response team (RT) with significant changes in condition. d. Document agreement with the previous assessment. e. Know and use the chain of command to get the needed resources

2345 Patient Safety - Failure to Rescue Practice Concept. abce The correct answers are: Use SBAR to communicate patient status changes immediately., Use checklists and standards to ensure quality care is provided, Activate the rapid response team (RT) with significant changes in condition., Know and use the chain of command to get the needed resources or response.

Question 39 The "transformational" Nurse Manager (NM) is called to visit an irate family because maintenance has neglected to fix a patient's leaky toilet for several days. What is the best conflict resolution action for the NM to take to promote client satisfaction (HCCAPS scoring)? (Select All That Apply) Select one or more: 1. Tell the patient's family there are more pressing issues. 2. Empathize with the family and voice an understanding of their frustration. 3. Hear the complaint first without interrupting the family as they explain. 4. Acknowledge that the family's concerns are important and will be addressed. 5. Offer to allow the family to move to a room elsewhere in the facility. 6. Ask family if they would like to sit and discuss their concerns over a beverage. PRE TEST 2 SATA Management of Care - HCCAPS and Service Recovery Original Question The Chief Nurse Officer (CO) is called to visit an irate family because maintenance has neglected to fix a patient's leaky toilet for several days. What is the best "service recovery" action for the CNO take to promote client satisfaction (improve HCCAPS scoring)? (Select All That Apply) Select one or more: a. Empathize with the families

23456 Answer: A, B, C, D, F The correct answers are: Empathize with the family and voice an understanding of their frustration., Acknowledge that the family's concerns are important and will be addressed., Ask family if they would like to sit and discuss their concerns over a beverage., Offer to allow the family to move to a room elsewhere in the facility., Hear the complaint first without interrupting the family as they explain.

Question 47 A nurse is giving a handoff report to a new nurse who will be caring for a client with soft medical restraints. The reporting nurse reminds the new nurse of the need to request a new prescription/order every _____ hours. Select one: 1. 12 hours 2. 8 hours 3. 24 hours 4. 4 hours

3

Question 9 The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, "I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will. When planning care for this client, which intervention is the most appropriate? Select one: 1. Encourage the client to allow for mechanical ventilation. 2. Educate the client on the purpose of mechanical ventilation. 3. Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so 4. Refer the client to a therapist to deal with the death of her mother.

3 Although it is appropriate to educate the client on mechanical ventilation, the client asked for information on making out a living will. It would be most appropriate at this time for the nurse to educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. The nurse should not attempt to convince the client to allow for medical treatment. The nurse may educate the client on a medical treatment, but that does not address the client's desire for a living will. There is no indication that this client needs therapy. Page Ref: 2842-2843 Concepts Cognitive Level: Applying

Question 46 A client is brought to the unit after a bronchoscopy with a biopsy. The client is experiencing new-onset confusion and is repeatedly attempting to get out of bed. Which action should the nurse take first? Select one: 1. Ensure one finger can be inserted between the restraint and patient's limb. 2. Apply medical arm and leg restraints then contact the provider for the order. 3. Assess the oxygen saturation via oximetry. 4. Explain the need for a restraint to the patient and family. 5. Get an order to give IV Lorazepam every 2 hours for agitation.

3 Because the patient is confused after a bronchoscopy it is important to assess the patient's oxygen saturation. To apply restraints without assessing the patient is not indicated. In addition, the patient is not at risk of harming himself, others or equipment. Caution: Trial release is not considered best practice. If the patient is well enough for trial release then the restraints should be removed all together. The correct answer is: Assess the oxygen saturation via oximetry.

Question 11 A new graduate nurse, who recently completed orientation, voices concerns about his shift assignment: "I have never taken care of anyone with an external ventricular device (EVD) before." Which action would be most appropriate for the charge nurse? Select one: 1. Check on the client's drain often during the shift. 2. Provide detailed teaching about the drain. 3. Reassign the patient with an EVD to an experienced nurses. 4. Transfer the new graduate nurse to another unit for the shift.

3 One of the first principles of safe assignments is to match skills with the care/ task. New nurses should not be assigned care/tasks for which they are not competent. The assignment needs to be changed to ensure patient safety. In addition the new nurse will require training before being assigned a client with an EVD. The correct answer is: Reassign the patient with an EVD to an experienced nurses.

Question 8 A bedridden client develops an open "pressure injury" or wound on the sacrum. On assessment, the nurse determines: the client's appetite is poor and has a pre-albumin level of 10.1 mg/dL. The client is unable to re-position without assistance. After three weeks in the hospital receiving treatment, wound care and antibiotic therapy, what action should the nurse take to promote optimal health? Select one: 1. Request a dietary review of the client's meal preferences. 2. Contact home health to establish a schedule for visits after discharge. 3. Make a referral to the case manager for discharge planning. 4. Consult with the physical therapist for repositioning schedule. 5. Discuss care concerns with the physician on rounds.

3 Pre-albumin level is10.1 mg/dL (Reference 16.0 to 35.0 mg/dL) the prealbumin test is a useful marker of nutritional status and was used to help detect and diagnose protein-calorie malnutrition as well as to monitor people receiving total parenteral nutrition (TP, getting nutrition via a solution injected into a vein). It was also used to monitor changes in nutritional status in someone undergoing hemodialysisas part of treatment for kidney disease. Changes in prealbumin may actually reflect other conditions such as inflammation, infection, or trauma. The correct answer is: Make a referral to the case manager for discharge planning.

Question 3 A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation? Select one: 1. Ask a staff nurse to question the client about the situation. 2. Ignore the situation until the client shows a willingness to talk. 3. Discuss the situation with the client in a private setting. 4. Ask the other staff members if abuse is involved.

3 The charge nurse should discuss the situation with the client in private and offer options of help. The charge nurse should not ignore the situation and should advocate for the client. The charge nurse herself should address this situation. The nurse should speak to the client first, not the staff, and not assume abuse until the client has given her version of events. Page Ref: 2716, 2721 Concepts Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity The correct answer is: Discuss the situation with the client in a private setting.

Question 38 A client feels that the nurse does not enter the room often enough and asks the nurse why there are so many clients on the assignment list. The best response by the nurse is: Select one: 1. "Most of the clients do not require as much care as you, so I can manage" 2. "No need to worry about my assignment list. You will get all the care you need." 3. "Staffing skill mix is a nurse sensitive indicator our Nurse Manager is monitoring." 4. "Due to economic constraints, hospital administrators have made staffing cuts." 5. "Clients are often admitted in poorer health so patient acuity has increased.

3 The correct answer is: "Staffing skill mix is a nurse sensitive indicator our Nurse Manager is monitoring."

Question 58 Research studies have shown decreased infection rates post gastrointestinal (GI) surgery are related to the staff-skill mix. Based on study results, the transformational nurse manager uses the PDSA model to implements a process improvement plan for increasing the number of RN staff. What is the primary impact of this plan on decreasing post-surgical GI infection rates? Select one: 1. Decreased staff overtime 2. A increase in client * satisfaction 3. A decreased mortality rate and cost of care 4. A decrease in the use of supplies

3 The correct answer is: A decreased mortality rate and cost of care Research has shown that an increase in RN staff decreases a unit's infection rate. Because infection is reduced, cost of care is also reduced. Overtime is not necessarily reduced by an increase in staff, depending on the number of nurses available at any given time. Studies show that client satisfaction increases with an increase of RN staff. There is no research that suggests that decreased infection rates will increase the need for client care supplies

Question 22 While preparing a client for surgery, the nurse marks the arm with the client that is to be amputated and participates in a "time out" procedure before the surgery begins. Which sentinel or never event should the "time out" procedure prevent? Select one: 1. Post operative surgical site infection. 2. Ineffective control of the client's phantom limb pain. 3. Amputation of the incorrect arm. 4. Over-sedation and respiratory depression post-procedure.

3 The correct answer is: Amputation of the incorrect arm. A sentinel event is an unexpected event that causes death or severe physical or psychological injury. The removal of the client's incorrect arm would be a sentinel event. Mild over-sedation is not a sentinel event as the client is most likely on a ventilator during surgery. The inability to heal properly is an expected event in a diabetic client. Pain control is individual and is not a sentinel event.

Question 68 Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP) who is assigned to a client with a diagnosis of Lung Cancer? Select one: 1. Perform mouth care on the client with an endotracheal tube inserted. 2. Reapply oxygen via nasal cannula to the client short of breath. 3. Take the urine sample to the lab 4. Teach the client how to ambulate with the walker 5. Restart the intravenous pump.

3 The correct answer is: Take the urine sample to the lab This is within the UAP's scope of practice.

Question 73 A school-age client is admitted to the PICU, unconscious and with a closed head injury and multiple traumatic injuries, after a skateboard accident. Many health professionals are involved. The parents are extremely anxious and want to know what's happening. The case manager asks for a health team meeting to speak with the client's parents. Which is the rationale for this meeting? Select one: 1. To allow the primary healthcare provider to make the decisions regarding care. 2. To allow for each specialty to practice interdependently 3. To coordinate and plan care in order to prevent conflicts and omissions in care. 4. To prevent the parents from trying to sue the hospital.

3 The correct answer is: To coordinate and plan care in order to prevent conflicts and omissions in care. Collaboration engages each professional's contribution to joint care planning. implementation, and accomplishment of client goals, with possibly less redundancy, more efficiency, and fewer care omissions. The parents of a minor child should be involved in all aspects of care and decision making.

Question 5 The nurse is preparing a client for discharge who will be requiring rehabilitation after a total knee replacement. After reading the healthcare provider's order, which action should the case manager take initially? Select one: 1. Teach the family the physical therapy exercises needed for the client. 2. Set up appointments with the inpatient physical therapy department. 3. Discuss the various rehabilitation settings and ask the client choose the venue 4. Call home health and schedule a home visit.

3 The nurse best exhibits the characteristic that the client has a right to self-determination by presenting the methods available for PT and answering the client's questions about each so the client can make an informed decision. The nurse would not refer the client for outpatient therapy unless the client requests that form of therapy. Scheduling home PT is leaving the client out of the decision-making process. The therapy that the client requires must be performed by a professional physical therapist. To teach the family exercises encroaches upon the expertise of the professional who will be performing the service. The correct answer is: Discuss the various rehabilitation settings and ask the client choose the venue.

Question 71 The nurse is caring for a client on a mental health unit who is yelling at other clients and some of the staff. Which verbal intervention by the nurse is most consistent with the concept of advocacy? Select one: 1. "You are out of control. You need to go to your room." 2. "You should be ashamed of your behavior. No wonder you ended up on a mental health unit." 3. "You seem upset. Can you tell me what you think might help to calm you down?" 4. "You need to behave. If this doesn't stop you are going to be placed in restraints."

3 The nurse's role is to advocate for the rights of the individual with mental illness or disability. The nurse should validate the meaning of the behavior and encourage safe coping methods. Disparaging the client or threatening to restrain them, isolate, or sedate them is inconsistent with client rights. Page Ref: 2719, 2720 Concepts Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity The correct answer is: "You seem upset. Can you tell me what you think might help to calm you down?'

Question 51 Which client should the charge nurse assign to the new graduate, novice nurse working on the respiratory unit? Select one: 1. The client with atelectasis, who is experiencing tachypnea and tachycardia. 2. The client diagnosed with lung cancer who has rust-colored sputum and pain of 10 on a scale of 1 to 10. 3. The isolated client with tuberculosis, who has a nonproductive cough and orange.colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 92% and has a capillary return >3 seconds. Benner's Model Which client should the charge nurse assign to the new graduate on the respiratory unit? 1. The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10 2. The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. 3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 92% and has a Capillary Return >3 seconds.

3 The orange-colored urine is secondary to rifampin, an antitubercular medication, and a non-productive cough is expected. Even though the patient is in isolation, this client is stable and should be assigned to a new graduate nurse 3 Rationale: 1. The client with lung cancer is expected to have rust-colored sputum; however, complaining of pain rated as a 10 warrants a more experienced nurse to assess the cause of the pain and medicate as needed. 2. The client with atelectasis (collapsed lung) who is having difficulty breathing needs a more experienced nurse to assess the client. This client is not stable. 3. The orange-colored urine is secondary to rifampin, an antitubercular medication, and a non-productive cough is expected. Therefore, this client is stable and should be assigned to a new graduate nurse. 4. The client is exhibiting respiratory compromise and is not stable. The pulse oximeter reading should be greater than 93% and the capillary return should be less than 3 seconds. Content - Medical/Surgical: Category of Health Alteration - Respiratory: Integrated Processes - Nursing Process: Planning: Client Needs - Safe and Effective Care Environment: Management of Care: Cognitive Level - Synthesis MAKING NURSING DECISIONS: The charge nurse should assign the most stable client to the new graduate nurse. The test taker must determine which client is exhibiting expected signs/symptoms and this client should be assigned to the new graduate nurse. Client's exhibiting signs/symptoms not expected for the client should be assigned to a more experienced nurse. The correct answer is: The isolated client with tuberculosis, who has a non-productive cough and orange-colored urine.

Question 21 A nurse is receiving a shift report about a group of assigned clients. Which of the following actions should the professional, competent nurse take first? Select one: 1. Complete the morning assessments for all assigned patients. 2. Check the lab findings of a client scheduled for surgery later in the shift. 3. Ask the provider about advancing a client's diet. 4. Suction the tracheostomy of a client who has copious secretions 5. Reinsert an intravenous catheter that was removed due to infiltration.

4 A nurse is receiving a shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? 1. Ask the provider about advancing a client's diet.Rationale: The nurse should ask the provider about advancing a client's diet so the client is able to increase his intake; however, the nurse should perform another action first. 2. Reinsert an intravenous catheter that was removed due to infiltration.Rationale: The nurse should reinsert an intravenous catheter to continue IV therapy; however, the nurse should perform another action first. 3. Suction the tracheostomy of a client who has copious secretions. - CORRECTRationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to suction the tracheostomy of a client who has copious secretions to clear the airway. 4. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.Rationale: The nurse should check the laboratory findings of a preoperative client to note any abnormalities prior to surgery; however, the nurse should perform another action first. The correct answer is: Suction the tracheostomy of a client who has copious secretions.

Question 37 A 59 yo. patient admitted with a diagnosis of a hemorrhaging duodenal ulcer has a Hgb of 6.5 gm/dl. "The prescription reads: "Type, Cross-match, and Transfuse 2 units of PRBCs." Which of the following quality care actions should be performed first and best demonstrate an "interdependent" role function based on the RN Scope of Practice? Select one: 1. Starting a new 18-gauge intravenous site for the prescribed transfusion. 2. Assessing the patient's temperature after starting the transfusion. 3. Priming the intravenous tubing with Ringers Lactate as prescribed. 4. Obtaining the patient's consent before requesting the prescribed units of blood from the laboratory. 5. Re-assessing the patient's temperature every hour after starting the transfusion.

4 Doherty Chapter 5 - Q. 3 in Case Scenario and Chapter 15 Interdependent - For Blood Transfusion, the physician writes the order for the transfusion, the nurse verifies and should ensure the consent is obtained before administering the blood. The nurse provides education regarding blood transfusion. This doesn't mean that it is the nurse's responsibility to obtain the consent, but the nurse's role as an advocate is to ensure the patient has been informed The correct answer is: Obtaining the patient's consent before requesting the prescribed units of blood from the laboratory.

Question 6 Which of the following is an advocacy intervention that a nurse may perform? Select one: 1. Deciding whether clients need to know information regarding their care. 2.Following organizational policies and procedures in all cases without question. 3.Leaving monitoring of clients' care to the clients themselves. 4. Ensuring that clients and their families understand their legal rights.

4 Educating clients and their families about their legal rights regarding informed decision-making is a specific advocacy intervention a nurse may make. Nurses should ensure that clients have all the information they need to give informed consent. They should review organizational policies and procedures to ensure protection of client rights, and they should monitor client care to ensure client rights.

Question 48 The charge nurse in the emergency department (ED) prepares for a client with traumatic limb amputation. The nurse assembles the health team to be present when the client arrives. Which is the rationale for why the charge nurse assembled the entire healthcare team? Select one: 1. Healthcare teams are assembled only to manage the care of critical care clients. 2. Teams are made up of members of the same profession to achieve one goal. 3. Healthcare teams exist only to make decisions for client discharge only. 4. Teams collaborate provide high-quality interprofessional health services.

4 Healthcare teams are made up of professionals from different areas of expertise, each with equal input and accountability, with the shared goal of delivering comprehensive, high-quality care to clients. Healthcare groups are made up of members of the same profession, and have one leader. Clients and families are included in the healthcare team's decision-making process. Healthcare teams are utilized anywhere in health care where multiple areas of expertise are needed, and not only for extremely ill clients. Equal input and accountability, with the shared goal of delivering comprehensive, high-quality care to clients. Healthcare groups are made up of members of the same profession and have one leader. Clients and families are included in the healthcare team's decision-making process. Healthcare teams are utilized anywhere in health care where multiple areas of expertise are needed, and not only for extremely ill clients. The correct answer is: Teams collaborate to provide high-quality, interprofessional health services.

Question 66 In a staff meeting, the Transformational Nurse Manager is reviewing the National Patient Safety Goals (NPSG) and specific QSEN competency considered when evaluating safety socks for a new fall prevention protocol. Which QSEN principle should the manager emphasize when explaining the importance of this process change? Select one: 1. Teamwork and Collaboration 2. Informatics 3. Communication 4. Quality Improvement 5. Patient Centered Care

4 New falls prevention protocol and evaluation of new safety socks are considered a Quality Improvement/ QSEN principle. Quality Glossary Definition: TQM A core definition of total quality management (TQM) describes a management approach to long-term success through customer satisfaction. In a TQM effort, all members of an organization participate in improving processes, products, services, and the culture in which they work. The correct answer is: Quality Improvement

Question 12 The nurse on a medical-surgical unit is asked to participate in data collection regarding skincare wellness and pressure injury prevention. What is the best reason for cooperating with this request? Select one: 1. Preventing staffing problems from arising in the unit promotes a better staff skill mix. 2. Fulfilling legal scope of practice requirements promotes process improvement. 3. Advancing the nursing profession is important for healthcare delivery. 4. Participating in a quality improvement is within the nursing scope of practice.

4 Quality improvement is the name for the processes used by an agency to measure and improve aspects of client care. The nurse may advance practice, but that is usually accomplished by returning to school for a higher degree. Preventing problems from arising is only one benefit of quality management. Nurses are encouraged to participate in quality improvement programs but are not legally required to do so. The correct answer is: Participating in a quality improvement is within the nursing scope of practice.

Question 61 What is the priority nursing action for a client who was admitted with GI bleeding and has removed the IV, and is insisting on signing them self out of the hospital against medical advice? 1. Tell the client not to leave the hospital since it is prohibited until they are discharged by the HCP. 2. Call security to prevent the client from leaving the hospital room. 3. Give the client the AMA paper to sign and help gather the client's belongings. 4. Encourage the client to stay in the hospital until more stable, but do not prohibit the client from leaving.

4 The client has not been involuntarily committed and has every right to leave the facility. Other options encourage the client to leave or may be considered false imprisonment. The correct answer is: Encourage the client to stay in the hospital until more stable, but do not prohibit the client from leaving

Question 26 A new nurse accidentally administers Heparin 5,000 units through the client's hemodialysis perm or vas catheter instead of the client's port-a-cath. What immediate actions should the nurse take? Select one: 1.Contact the client's family to fully disclose the event. 2.Contact the dialysis nurse to schedule emergent dialysis. 3.Attempt to aspirate the heparin from the catheter. 4.Ask the patient to avoid bearing down during the bowel movement.

4 The correct answer is: Ask the patient to avoid bearing down during the bowel movement. UNIT TEST 3 Management of Care: Legal Never Events Medical Errors ORIGINAL QUESTION A new nurse accidentally administers Heparin 5,000 units through the client's hemodialysis perm or vas catheter instead of the client's port-a-cath. What immediate actions should the nurse take? (Select All That Apply) Select one or more: a.Contact the dialysis nurse to schedule emergent dialysis. b.Notify the manager on-call of the event. c.Contact the client's family to fully disclose the event. d.Inform the patient of the mistake. e.Ask the patient to notify the nurse with the urge to have a bowel movement. f.Ask the patient not to shave or brush his teeth. g.Contact the provider for further orders. h.Attempt to aspirate the heparin from the catheter. E F G

Question 2 The nurse is caring for a client with rheumatoid arthritis who expresses the desire to remain active as long as possible. In order for the client to meet this overall goal, what should the nurse prepare to do? Select one: 1. Teach the client nutrition and joint exercises. 2. Ask the client the reason for the decision. 3. Tell the client there is no hope. 4. Refer the client to the appropriate professionals.

4 The number of clients with chronic diseases with healthcare needs is increasing rapidly, and nurses and primary healthcare providers cannot meet all of these clients' needs. When a client expresses the desire to live as normally as possible, the nurse should refer the client to professionals who can hep the client meet that goal. The nurse can teach some nutrition and exercise but cannot go into the depth that this client would need. The client with a chronic disease should not be told there is no hope but should be helped toward reaching desired goals. Asking the client the reason for the decision is irrelevant to the situation. The correct answer is: Refer the client to the appropriate professionals.

Question 32 The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate? Select one: 1. Asking to be assigned to a different client 2. Referring the parents to social services 3. Telling the parents they are making the right decision 4. Respecting the parents' decision

4 The nurse best advocates for the family by supporting the family's right to make this decision. Tell the clients they are making the right decision is inappropriate and does not support advocacy. Referring the parents to another entity points to feelings of unease about the parents' choice. Asking to be assigned to another client does not honor the right of clients and families to make decisions about healthcare. Page Ref: 2716 Concepts Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity The correct answer is: Respecting the parents' decision

Question 10 The nurse on the medical unit is admitting a client. When the nurse asks the client about advance directives, the client states, "I have a living will." Which is the purpose of a living will? Select one: 1. Provides specific instructions about how decisions are to be made if the client is unable to make the decisions 2. Provides specific instructions about who will make healthcare decisions if the client cannot 3. Provides specific instructions about type of medications the client requires to sustain life 4. Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves

4 There are two types of advanced directives, the living will and the durable power of attorney for healthcare. The living will provides specific instructions about what medical treatment the client chooses to omit or refuse. The durable power of attorney for healthcare identifies who will be making healthcare decisions if the client cannot. Living wills do not dictate medication requirements or how decisions are to be made if the client cannot make them Page Ref: 2843 Concepts Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care The correct answer is: Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves

Question 23 The nurse is preparing to administer Bumetanide to a client with a BNP of 4,000 pg/ml. For which of the following findings should the nurse withhold the medication and contact the provider? Select one: 1. Serum potassium level of 3.6 mEg/L 2. Sinus rhythm with a pulse rate 116/min 3. Serum sodium level of 139 mEq/L 4. BP 98/48 mmHg

4 Your answer is correct. Bumetanide is a loop diuretic that acts to decrease circulating fluid volume. It is useful in the treatment of pulmonary edema and heart failure. The nurse should monitor the client's BP and, if the client is hypotensive, the nurse should withhold the medication and notify the provider. To calculate a mean arterial pressure, o 2x dbp+sbp/3 Bumetanide is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease. This can lessen symptoms such as shortness of breath and swelling in your arms, legs, and abdomen. Bumetanide is a "water pill" (diuretic) that causes you to make more urine. BNP - A normal level of NT-proBNP, based on Cleveland Clinic's Reference Range is: Less than 125 pg/mL for patients aged 0-74 years. Less than 450 pg/mL for patients aged 75-99 years. The correct answer is: BP 98/48 mmHg

Question 54 An 89 yo. bedridden Medicare client admitted for a change in mental status develops a stage 4 wound on his sacral area. The nurse notes the client's most recent pre-albumin level is at 10.1 mg/dL. Which action should the nurse take to ensure discharge planning goals are met? Select one: 1. Contact the primary provider for new wound treatment orders 2. Request an order to culture the wound and place the client on contact isolation 3. Ask the dietitian to review the client's nutritional status 4. Report the client's status change on rounds 5. Discuss the client's needs with the team to ensure appropriate care planning

5 Prealbumin, also referred to as transthyretin, is a transport protein for thyroid hormone. It is synthesized by the liver and partly catabolized by the kidneys. Normal serum prealbumin concentrations range from 16 to 40 mg/dL; values of <16 mg/dL are associated with malnutrition. The correct answer is: Discuss the client's needs with the team to ensure appropriate care planning

Question 52 The nurse is working on a unit that is short staffed. The manager was unable to replace the nurse, so the extra patients were reassigned to the remaining nurses. The manager however was able to get the help of a float pool UAP. In order for safe and effective care to be delivered, the nurses would: Select one: 1. Explain to the manager that quality care will be compromised. 2. Tell the patients of the UAP limitations and which tasks the UAP may perform. 3. Refuse the assignment and report to the chain of command. 4. To improved satisfaction scores, inform the clients their care may be scarce. 5. Delegate appropriate tasks to the UAP.

5 The correct answer is: Delegate appropriate tasks to the UAP.

Question 56 The nurse provides medication to a client at the wrong time. No harm came to the client as a result of the nurse's error and the nurse files a report about the medication error. Which just culture response by the risk management team is most appropriate? Select one: a. Implement system-wide policy changes to prevent future errors. b. Monitor all nurses on the unit to ensure this does not occur again. c. Report the nurse to the board of nursing. d. Discipline the nurse appropriately.

A The correct answer is: Implement system-wide policy changes to prevent future errors. When a nurse makes an error and reports it, the risk management team will investigate to discover causes for the error and effect policy changes that can prevent future errors, improving the level of client care. The situation does not warrant reporting the nurse to the board of nursing. The risk management team would not be responsible for implementing any disciplinary actions. It is not prudent for the risk management team to monitor all nurses who administer medications on the unit

Question 15 The health care provider has written the admission prescriptions for a client diagnosed with pneumonia. Considering the core measures, prioritize how the nurse should complete the prescription/orders listed below: A. Administer oxygen at 2 liters per nasal cannula. B. Fingerstick blood sugar before meals and at bedtime. C. Administer Ceftriaxone 1 gram every 12 hours intravenously. D. Collect blood and sputum cultures prior to the antibiotic. First Second Third Fourth

A. 1 B. 4 C. 3 D. 2

Question 57 You are the home care nurse committed to providing quality care. You have adjusted your schedule to visit the following four patients today. Which patient will you see in order of priority? A. A patient with schizophrenia, in need of a Risperidone injection. B. A newly discharged patient who needs an initial assessment after a recent AMI and stent placement. C. A patient w/ COPD complaining of increased SOB with an 02 Sat of 91-92%. D. A patient receiving weekly chemotherapy, who needs blood drawn for lab analysis. FIRST SECOND THIRD FOURTH

A. 3 B. 2 C. 1 D. 4 ANSWER 1 Mr. Adams' increased SOB indicates a need for rapid assessment. In addition, high oxygen flow rates can cause an increase in the partial pressure of carbon dioxide (paco2) and suppression of respiratory drive in pts. with COPD, so Mr. Adams should be seen as soon as possible. The other pts. can be scheduled according to their status and then their location or patient preference about visit time. Risperdal Consta® (risperidone long-acting injection) should be received every 2 weeks. The correct answer is: A patient with schizophrenia, in need of a Risperidone injection. THIRD A newly discharged patient who needs an initial assessment after a recent AMI and stent placement. SECOND A patient w/ COPD complaining of increased SOB with an 02 Sat of 91-92%. FIRST A patient receiving weekly chemotherapy, who needs blood drawn for lab analysis. FOURTH

Question 77 A client newly diagnosed with prostate cancer and a radioactive seed implant is preparing for discharge. According to the RN scope of practice, nurses provide safe and effective care by: (Put in order of priority) A. Evaluating the availability of resources to support the clients level of care at home B. Implementing measures to address nurse sensitive indicators, such as a falls risk potential. C. Establishing an optimal critical pathway/plan to achieve positive outcomes D. Assessing the client's vital signs and physical status per policy. E. Developing a plan with the health team based on identified discharge needs. First Second Third Fourth Fifth

A. 5 B. 4 C. 3 D. 1 F. 2 A client newly diagnosed with prostate cancer and a radioactive seed implant is preparing for discharge. According to the RN scope of practice, nurses provide safe and effective care by: (Put in order of priority) Select one or more: Nursing Process Scope of Practice - Components of the RN Practice 1. Assessing the client's vital signs and physical status per policy [ Assessment] 2. Developing a plan with the health team based on identified discharge needs. [Plan] 3. Establishing an optimal critical pathway/plan to achieve positive outcomes. [Plan] 4. Implementing measures to address nurse sensitive indicators, such as falls risk potential [Implementation] 5. Evaluating the availability of resources to support the clients level of care at home. [Evaluation]

Question 76 Nicole an 18 yo. client with a PMH of leukemia is admitted with a temp of 38.8°C (101.8 °F) that did not respond to the every 4-hour acetaminophen taken at home. Her admission assessment indicates Nicole's lung sounds are clear, heart sounds (S1 S2) are strong and peripheral pulses are +2 and regular with a MAP of 60 mmH . She is in no apparent pain or distress. The skin assessment reveals alopecia and white patches in her mouth. Her admission laboratory values include: Hematology Report: Hemoglobin: 10.1 g/dL; Hematocrit: 25%; Platelets: 50,000/mm3; White blood cell count:2,000/mm3; Differential: Neutrophils 20% The nurse starts fluid resuscitation according to the Surviving Sepsis Bundle. Two hours later, the nurse uses a decision-making framework to determine which findings to report as improving, worsening or unrelated. A. Temp= 35.8°C (96.4 °F) and complaint of chills B. Skin assessment - alopecia w/ shiny forehead C. Hemoglobin: 10.1 g/dL and Hematocrit: 22% D.Serum pre-albumin down to 10 mg/dL from the previous admission. E. Serum potassium of 3.5 mEg/L F. Monocytes: 16% G. MAP of 65 mmHg H. Peripheral pulses of +1 and a CVP down to 2 cmH2O I. Neutrophils (or Se

A. W B. U C. W D. U E. U F. W G. I H. W I. W Nicole an 18 yo. client with a past medical history of leukemia is admitted with a temperature of 38.8°C (101.8 °F) that did not respond to the every 4-hour acetaminophen taken at home. Her admission assessment indicates Nicole's lung sounds are clear, heart sounds (S1 S2) are strong and peripheral pulses are +2 and regular with a MAP of 60. She is in no apparent pain or distress. The skin assessment reveals alopecia and white patches in her mouth. Her admission laboratory values include: Hematology_Report: Hemoglobin: 10.1 g/dL Hematocrit: 25% Platelets: 50,000/mm3 White blood cell count: 2,000/mm Differential: Neutrophils 20% The nurse starts fluid resuscitation according to the Surviving Sepsis Bundle. Two hours later, the nurse uses a decision-making framework to determine which findings to report as improving, worsening or unrelated. References WBC Differential: The differential consists of the percentage of each of the five types of white blood cells. Normal values for ditterential are: o Bands or stabs: 3 - 5% o Neutrophils (or segs): 50 - 70% relative value (2500-7000 absolute value) o Eosinophils: 1 - 3% relative value (100-300 absolute value) o Basophils: 0.4% - 1% relative value (40-100 absolute value) o Lymphocytes: 25 - 35% relative value (1700-3500 absolute value) o Monocytes: 4 - 6% relative value (200-600 absolute value) Pre-albumin blood test are: Adults: 15 to 36 milligrams per deciliter (mg/dL) or 150 to 360 milligrams per liter (mg/L). When pre-albumin levels are lower than normal, it may be a sign of a poor diet (malnutrition). Low Central Venous Pressure A decrease in central venous pressure is noted when there is more than 10% of blood loss or shift of blood volume. The correct answer is: Temp= 35.8°C (96.4 °F) and complaint of chills. Worsening Skin assessment - alopecia w/ shiny forehead. Unrelated Hemoglobin: 10.1 g/dL and Hematocrit: 22%. Worsening Serum pre-albumin down to 10 mg/dL from the previous admission. Unrelated Serum potassium of 3.5 mEg/L. Unrelated Monocytes: 16%. Worsening MAP of 65 mmHg. Improving Peripheral pulses of +1 and a CVP down to 2 cmH20. Worsening Neutrophils (or Segs): 85%. Worsening

Question 29 A nurse discovers that a client was administered enalapril in error. Number the following actions in the appropriate sequence that the nurse should follow. A.Notify the Risk Manager B.Monitor the client's vital signs C.Instruct the client to remain in bed until further notice D.Complete an incident report E.Call the client's provider

A.5 B.1 C. 2 D. 4 E. 3 ACE inhibitors have proven to be very effective in the treatment of heart failure caused by systolic dysfunction (e.g., dilated cardiomyopathy). Beneficial effects of ACE inhibition in heart failure include: o Reduced afterload, which enhances ventricular stroke volume and improves ejection fraction.Reduced preload, which decreases pulmonary and systemic congestion and edema. o Reduced sympathetic activation, which has been shown to be deleterious in heart failure. o Improving the oxygen supply/demand ratio primarily by decreasing demand through the reductions in afterload and preload. o Prevents angiotensin Il from triggering deleterious cardiac remodeling.

The LPN/LVN whom you are supervising comes to you and says, "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the physician of the incorrect medication dose. 5. Place the client on a telemetry monitor.

Ans: 1, 5, 4. 3. 2 REVISED 1. Assess the client's heart rate. 5. Place the client on a telemetry monitor. 4. Notify the physician of the incorrect medication dose. 3. Ask the LP/LVN to explain how the error occurred. 2. Complete a medication error report. The first action after a medication error should be to assess the client for adverse outcomes. You should evaluate this client for symptoms such as bradycardia and excessive salivation. These may indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The physician should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report. Focus: Prioritization The correct answer is: Complete a medication error report. 5 Ask the LP/LVN to explain how the error occurred. 4 Place the client on a telemetry monitor. 2 Notify the physician of the incorrect medication dose. 3 Assess the client's heart rate. 1

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? Select one: 1. Changing the pouch before a meal. 2. Positioning the client standing or supine. 3. Cleansing the peristomal skin with alcohol. 4. Measuring and assessing the stoma.

Answer: 3. Cleansing the peristomal skin with alcohol. Rational: This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol. Can be cleansed with warm water. You would change the pouch before a meal to help prevent build up of gas. You would position the client standing or supine to make sure the abdomen is flat so the colostomy bag fits properly. You want to measure the stoma so you get the right fit when cutting the wafer/barrier. You always assess the stoma to make sure the color is appropriate and the amount of bleeding is in range.

-How would prioritize these tasks when changing a colostomy bag? 1. Apply gloves 2. Remove old pouch and place in a biohazard bag/bag and then place in the trash. 3. Measure stoma and cut wafer to size 4. Empty colostomy pouch 5. Use adhesive remover on old wafer 6. Assess stoma and skin 7. Wash hands 8. Cleanse the stoma and the skin around the stoma with warm water 9. Apply skin barrier 10. Apply wafer and pouch

Answer: 7, 1, 4, 5, 2, 6, 8, 3, 9, 10 Rationale: The steps should be placed in this order to prevent infection and have the barrier to apply correctly. Reference: https://medlineplus.gov/ency/patientinstructions/000204.htm The correct answer is: 7, 1, 4, 5, 2, 6, 8, 3, 9, 10

Question 75 Providing quality care is essential for positive patient outcomes and dependent on a variety of factors. Which of the following does the nurse understand to be the most important QSEN competency? Select one: a. Documenting an accurate assessments in the electronic medical record b. Developing a collaborative interprofessional plan to address care needs c. Assessing the client's progress toward achieving his ambulation goals d. Determining appropriate resource utilization while hospitalized

B There are six QSEN competencies that were developed for pre-licensure and graduate nursing programs: patient-centered care, teamwork and collaboration, evidence- based practice (EBP), quality improvement (QI), safety, and informatics.The correct answer is: Developing a collaborative interprofessional plan to address care needs

Question 36 The client's case manager, diabetes educator, and nutritionist ask to meet to discuss the client's needs in preparation for discharge to home. The client's primary healthcare provider arrives and states, "I will be making all decisions regarding the client's discharge care." Using the assertive communication, how should the nurse respond? Select one: a. "'You're being an in-civil, bully unconcerned about quality care" b. "The team meeting is not needed, if you will write the new orders" c. "If we collaborate, the patient will benefit from coordinated care" d. "Clients have a right to interprofessional collaboration"

C Interdisciplinary teams include professionals of varied backgrounds who collaborate and share in decision making for positive client outcomes. The term interprofessional team is synonymous with interdisciplinary team. The correct answers are: "If we collaborate, the patient will benefit from coordinated care", "Clients have a right to interprofessional collaboration"

Question 78 A graduate nurse is performing ostomy care for a client with a new colostomy. How should the nurse prioritize the care when changing the colostomy bag? 1. Apply gloves 2. Remove old pouch and place in a biohazard bag/bag and then place in the trash. 3. Measure stoma and cut wafer to size 4. Empty colostomy pouch 5. Use adhesive remover on old wafer 6. Assess stoma and skin 7. Wash hands 8. Cleanse the stoma and the skin around the stoma with warm water 9. Apply skin barrier 10. Apply wafer and pouch Select one: а. 7, 4, 5, 1, 2, 6, 8, 3, 9, 10 b. 7, 1, 5, 2, 6, 3, 8, 9, 10, 4 c. 7, 1, 4, 5, 2, 6, 3, 8, 9, 10 d. 7, 1, 4, 5, 2, 6, 8, 3, 9, 10

D Doherty Chapter 5 - GI Basic Care and Comfort

Question 59 An experienced RN on the respiratory unit is making assignments based on the staff skill-mix, client acuity, and nurse-sensitive indicators. Which components of the Nursing Scope of Practice must the RN consider when safely assigning and supervising nursing activities? Select one: 1. Delegating overall accountability for assigned clients and all delegated tasks. 2. Validating and ensuring the competence of assigned nursing staff. 3. Overseeing the direct supervision all members of the health team. 4. Providing direct observation and evaluating all nursing care given.

NCBON Nurse Practice Act AT Leadership and Management 2 The correct answer is: Validating and ensuring the competence of assigned nursing staff. Staff Development and Staff Orientation - ATI Leadership and Management