Proctored Leadership Pt.2
40. A facility infection control nurse is reviewing the reports of a group of clients. Which of the following infections should the nurse report to the public health department? a. Lyme disease b. Bacterial conjunctivitis c. Health care-acquired pneumonia d. MRSA
a. Lyme disease
46. A nurse is teaching a class of newly licensed nurses about evidence-based practices. The nurse should include which of the following as the first step in evidence-based practice? a. Apply research to client care practice b. Develop a clinical question c. Critically assess the evidence d. Collect evidence from a variety of sources
b. Develop a clinical question
7. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (SATA) [repeat] • A wheeled office chair at the client's computer desk • A raised vinyl seat on the toilet in the bathroom • A throw rug covering some cracked floor • A folding chair without arm rests • A two wheeled walker used to assist the client with ambulation
A wheeled office chair at the client's computer desk A throw rug covering some cracked floor A folding chair without arm rests
50. A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. Which of the following responses should the charge nurse make? a. "Please stop discussing the client in a public area" b. "Do you understand the HIPAA regulations?" c. "We should discuss your concerns with the client's care team" d. "I will notify the client's provider about this breach of confidentiality
a. "Please stop discussing the client in a public area"
29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage tracheostomy at home? (SATA) a. Pipe cleaners b. O2 Tank c. Cotton balls d. Petroleum Jelly e. Obturator
a. Pipe cleaners b. O2 Tank e. Obturator
34. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "I should encrypt personal health information when sending emails." b. "I can post the client's vital signs in the client's room." c. "I can use another nurse's password as long as I log off after using the computer" d. "I should discard personal health information documents in the trash before leaving the unit"
a. "I should encrypt personal health information when sending emails."
39. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? a. "It's not too late to cancel the surgery if you want to" b. "Why did you make the decision to have this procedure?" c. "This won't take long and it will be over before you know it" d. "You shouldn't be worried because the procedure is very safe"
a. "It's not too late to cancel the surgery if you want to"
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse? a. A client who has multiple sclerosis and ataxia b. A client who has brain tumor and is admitted for chemotherapy c. A client who has guillain-barre syndrome and a tracheostomy d. A client who sustained a concussion and is being monitored for complication
a. A client who has multiple sclerosis and ataxia
11. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first? a. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea c. A client who has pneumonia and requires a tracheostomy dressing change d. A client who has a new colostomy and requires discharge teaching
a. A client who is 4 hr postoperative following a hernia repair and has pitting
67. A nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client's partner asks the nurse how that would help. The nurse should explain the respite care would do which of the following? a. Allow her to take time off from attending to her partner b. Provide volunteers who will run errands for her c. Send a clinician to assess the safety of leaving her partner alone d. Help her arrange transferring her partner to an assisted living facility 68
a. Allow her to take time off from attending to her partner
24. A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps for medication administration. Which of the following is priority action by the charge nurse? a. Assess the staff nurse's knowledge deficit. b. Pair an inexperienced nurse with an experienced nurse. c. Demonstrate use of the pump during medication administration. d. Plan an in-service education program on the unit
a. Assess the staff nurse's knowledge deficit.
15. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? a. Decreased level of consciousness b. Generalized rash over trunk c. Increased temperature d. Report of photophobia
a. Decreased level of consciousness
43. A charge nurse witnessed an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? a. Discuss the issue with the AP b. Notify the unit manager about the incident c. Reinforce facility protocols at the next staff meeting d. Alert the infection control department
a. Discuss the issue with the AP
19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client's reasons for refusing surgery
a. Discuss with the client her concerns regarding the procedure
13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment b. Irrigate the exposed area with water c. Remove the client's clothing d. Report the incident to OSHA
a. Don personal protective equipment
5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? a. Identify the industry standards for infant safety b. Evaluate the selected infant safety system c. Choose an infant safety system d. Establish measurement criteria for infant safety systems
a. Identify the industry standards for infant safety
48. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Libel b. Negligence c. Battery d. Slande
a. Libel
56. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care? (SATA) a. Nutritional therapists b. Case Manager c. Mental Health counselor d. Occupational therapist e. Physical therapist
a. Nutritional therapists b. Case Manager c. Mental Health counselor
2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first? a. Obtain a breakfast tray for a client who received a morning dose of insulin as part b. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400 c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours. (To prevent bacterial contamination, fill the bag with only enough formula to last over a 4-8 hour period, and change the feeding bag every 24 hours)
a. Obtain a breakfast tray for a client who received a morning dose of insulin as part
21. A nurse is planning to delegate client care assignment. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Performing postmortem care prior to transferring the client to the morgue b. Advising a client on self-administration of acetaminophen c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Informing a family of a client's progress in physical therapy
a. Performing postmortem care prior to transferring the client to the morgue
care 33. A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Positions the client on her left side with knees flexed b. Administers the solution at room temp c. Points tubing in the direction of the umbilicus during insertion d. Inserts the tubing 8cm (3.1 in) into the rectum
a. Positions the client on her left side with knees flexed
3. A nurse is completing performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile. b. The AP closes the door of a client who is on airborne precautions. c. The AP Removes cut flowers from the room of a client who is in protective environment. d. The AP wears a mask when a caring for a client who has varicella.
a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile.
60. A nurse on a med surg unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? a. "You must choose a member of your family to serve as a your health care proxy." b. "A health care proxy can make decisions for you when you are unable to do so." c. "You should appoint a health care proxy before undergoing an invasive procedure." d. "It is necessary for an attorney to approve your health care proxy."
b. "A health care proxy can make decisions for you when you are unable to do so."
31. A nurse is discussing the safekeeping of valuables with a client who is scheduled for surgery. Which of the following client statements indicates the need for further teaching? a. "I can wear my ankle bracelet since i am just having a local anesthetic: b. "I can leave my wedding ring on if it is taped in place" c. "I should remove my dentures before the procedure" d. "I should leave my valuables with a family member"
b. "I can leave my wedding ring on if it is taped in place"
16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a. Antibiotic therapy was initiated 2 hr after implementation of the care pathway. b. A blood culture was obtained after antibiotic therapy had been initiated c. An allergy to penicillin required an alternative antibiotic to be prescribed d. The route of antibiotic therapy on the care pathway was changed from IV to PO
b. A blood culture was obtained after antibiotic therapy had been initiated
8. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse assign to a LPN. a. An older adult who has lung cancer and has periodic episodes of severe dyspnea b. A middle adult client who has a below the knee amputation and requires a dressing change c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus d. An adolescent who requires teaching regarding insulin administration
b. A middle adult client who has a below the knee amputation and requires a dressing change
30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? a. An adult client who has alcohol intoxication- NOT FOCUSED b. An adolescent client who is legally emancipated c. An older adult client who has questions about the procedure= having questions means you don't understand, d. An adult client who has moderate Alzheimer's disease.- cant consent if you are not FOCUSED
b. An adolescent client who is legally emancipated
61. A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Which of the following actions should the nurse take first? a. Consult the pharmacist about the client's prescribed medications. b. Compare the client's medication administration record with the prescriptions on the transfer orders. c. Review the intended purpose of the prescribed medication with the client. d. Call the provider to clarify the clients prescribed medications.
b. Compare the client's medication administration record with the
1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. a. Erythema on the skin surrounding a client's wound b. Deep red color on the center of the clients wound c. Inflammation noted on the tissue edges of a client's wound d. Increase in serosanguineous exudate from the clients wound
b. Deep red color on the center of the clients wound
12. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working on the night shift. Which of the following actions should the nurse manager take first? a. Acknowledge the conflict and encourage the nurses to focus on working as a team b. Gather information regarding the situation c. Encourage the nurses to resolve the conflict autonomously d. Meet with a committee from each shift to discuss issues related to the conflict
b. Gather information regarding the situation
14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? a. Complete an incident report b. Measure the client's vital signs c. Inform the nurse manager d. Call the provider
b. Measure the client's vital signs
26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? a. Treat the client's injuries within 30 min b. Provide treatment for life-threatening injuries c. Provide treatment for minor injuries d. Allow the client to die without further intervention
b. Provide treatment for life-threatening injuries
42. A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first a. Write down the complete prescription b. Read back the prescription to the provider c. Document the prescription as a telephone prescription in the medical record d. Ensure that the provider signs the prescription
b. Read back the prescription to the provider
53. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? a. Advise him to complete the less time consuming tasks first b. Recommend that he take time to plan at the beginning of his shifts c. Offer to provide care for his clients while he take a break d. Ask other staff members to take over some of his tasks
b. Recommend that he take time to plan at the beginning of his shifts
47. A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualty incident in the community. As clients arrive at the designed triage area outside the hospital, which of the following actions should the nurse take?. a. Place shower caps over the client's' hair b. Remove contaminated clothing c. Scrub the client's skin with betadine solution d. Admit the injured clients to positive-pressure rooms
b. Remove contaminated clothing
45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? a. Initiate contact precautions (standard) b. Report the infection to the local health department c. Apply an antiviral cream to lesions d. Instruct the client to use condoms until the treatment is completed (NO, not 100% preventable)
b. Report the infection to the local health department
51. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? a. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape b. Uses sterile forceps to pack sterile gauze into the wound c. Sets up the sterile field 30 min prior to performing the dressing change d. Uses a sterile-gloved hand to adjust the back of the sterile gown
b. Uses sterile forceps to pack sterile gauze into the wound
68. A charge nurse observes a client fall during ambulation and notes that his gait belt was not in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the following ethical principles should guide the nurse's subsequent actions? a. Non maleficence - do no harm b. Veracity - commitment to tell the truth c. Fidelity - keep promises d. Beneficence - promote good for other
b. Veracity - commitment to tell the truth
52. A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? a. Place the client in a negative-pressure airflow room b. Perform hand hygiene with alcohol based hand sanitizer. c. Clean the equipment in the client's room with bleach. d. Initiate droplet precautions for the client.
c. Clean the equipment in the client's room with bleach.
58. A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority? a. A client who has depressive disorder and has poor personal hygiene b. A client who has dementia and exhibits aphasia c. A client who has bipolar disorder and displays constant pacing - (Can lead to physical exhaustion and death) d. A client who has schizophrenia and uses neologisms
c. A client who has bipolar disorder and displays constant pacing - (Can lead to physical exhaustion and death)
10. A nurse is caring for a group of clients. Which of the following should the nurse see first? a. A client who is postoperative and has a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing c. A client who has diabetes mellitus and is diaphoretic d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10
c. A client who has diabetes mellitus and is diaphoretic
62. A nurse on a med surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who is postoperative following laminectomy 12hrs ago is unable to void b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy c. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot d. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38C (101F
c. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? a. A client who is post term and is receiving oxytocin for labor induction b. A client who gave birth to her first child and requires instruction on breastfeeding techniques c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating
57. A nurse is prioritizing care after a receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? [repeat] a. A client who reports a headache with sensitivity to light. b. A client who reports feeling lightheaded when he stands up from a lying position c. A client who reports indigestion and pain in her jaw d. A client who reports an urge to void but has not urinated during the prior shift
c. A client who reports indigestion and pain in her jaw
32. A nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? a. Request the consultation after several wound care treatments are tried b. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatments c. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation d. Provide the consultant with subjective opinions and beliefs about the client's wound care
c. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation
70. A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching? a. Remove the client's restraints every 2 hr. b. Allow 1 fingerbreadth between the restraint and the client's wrists c. Attach the restraints to the fixed portion of the frame of the client's bed d. Secure the client's restrains with a square knot
c. Attach the restraints to the fixed portion of the frame of the client's bed
38. A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? a. Place a faulty equipment tag on the pump b. Notify the provider c. Auscultate the client's lungs d. Complete an incident repor
c. Auscultate the client's lungs
25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? a. Administer the initial bolus feeding to a client who has NG tube b. Check a client pain level 30min after receiving acetaminophen c. Collect urine specimen for newly admitted client d. Instruct a client to splint an abdominal incisions
c. Collect urine specimen for newly admitted client
37. A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Use root cause analysis to identify gaps in meeting standards- root cause analysis is done if the benchmark is not met b. Establish work initiatives to promote a positive environment c. Compare practices within the facility against other high-performing facilities d. Determine how current practice will affect future performance within the facility
c. Compare practices within the facility against other high-performing facilities
36. A charge nurse observe a licensed practical nurse tell a client that she will return with a medication to help relieve the client's nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ethical principles with the LPN? a. Veracity b. Justice- c. Fidelity d. Nonmaleficence
c. Fidelity
9. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority for the nurse to take? a. Remind nurses to obtain this information during the admission process b. Reinforce the potential consequences of not having his information on record to the nursing staff c. Meet with nursing staff to review the policy regarding advance directive d. Ask nurse who are caring for client without his information in the medical record to obtain it
c. Meet with nursing staff to review the policy regarding advance directive
63. A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? a. Plan to administer an antiviral medication to the client. b. Wear an N95 respirator mask while caring for the client. c. Prepare to administer antibiotics to the client. d. Place a surgical mask on the client during transfer to the unit
c. Prepare to administer antibiotics to the client.
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist
c. Speech therapist
35. A nurse is participating on a committee that is considering the creation of a policy that will allow the nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy? (2016 practice) a. ANA Standards of Practice b. ANA Code of Ethics c. State Nurse Practice Act d. Institute of medicine
c. State Nurse Practice Act
54. A nurse is planning discharge for a client who has lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral? a. The client needs to have someone bring O2 tanks and equipment to her home b. The client needs to have range-of-motion exercises to assist with ambulation c. The client needs to arrange financial resources to purchase equipment d. The client needs to have someone come in to help her bathe at home
c. The client needs to arrange financial resources to purchase equipment
55. A nurse initiates a referral to an occupation therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? a. The client reports pain when chewing solid foods. b. The client expresses the desire to join a support group. c. The client requires assistance with completing oral hygiene d. The client has difficulty ambulating with a walker
c. The client requires assistance with completing oral hygiene
7. A home health nurse is performing a safety assessment of a client's home. Which of the following findings should the nurse identify as a safety hazard? a. The client has used tracks to secure the carpet on the stairs b. The client's electrical cord is taped to the floor c. The client's bedside lamp is plugged in using an extension cord with two prongs d. The client stores cleaning supplies in a locked cabinet above his head
c. The client's bedside lamp is plugged in using an extension cord with two prongs
4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? a. "Once I sign my living will, a family member must co sign it" b. "I will wait until I have a serious health problems to sign my advance directives" c. "My doctor will need to provide approval for the decisions outlines in my living will d. "My durable power of attorney for health care is part of my advance directives"
d. "My durable power of attorney for health care is part of my advance directives"
66. A nurse is speaking with a visitor who asks a questions about the status of a relative who is a fadovclient on the unit. Which of the following responses by the nurse is appropriate? a. "I'm not taking care of your relative today, so I don't have the latest information" b. "I will have your relative's nurse come and talk with you about her care." c. "Let me check your relative's medical record to see how she's doing." d. "Please ask your relative about this, because I cannot share information about her."
d. "Please ask your relative about this, because I cannot share information about her."
49. A nurse is preparing to complete morning assignments on several assigned clients. Which of the following clients should the nurse plan to assess first? a. A client who had a bladder scan that indicated 250 mL of urine in the bladder b. A client who is 3 days postoperative and who's dressing has serosanguinous drainage c. A client who has diabetes and an early morning blood glucose of 220 mg/dL d. A client who has a nasogastric tube to intermittent suction and reports nausea
d. A client who has a nasogastric tube to intermittent suction and reports nausea
69. A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process? a. Place a photocopy of the signed consent in the client's medical record b. Review the risks and benefit of the procedure with the client c. Discuss alternative treatment options with the client d. Assess the client's understanding after the provider has talked with her
d. Assess the client's understanding after the provider has talked with her
65. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a. False imprisonment b. Libel c. Assault d. Battery
d. Battery
59. A nurse is planning care for a group of clients. Which of the following action should the nurse take first? a. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs ago. b. Auscultate the bowel sounds of a client who has not had bowel movement after taking a laxative 12hr ago. c. Provide instruction to the caregiver of a client who has dementia and new diagnosis of diabetes mellitus. d. Check a client who has a leg cast and reports a new onset of pain
d. Check a client who has a leg cast and reports a new onset of pain
64. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? [repeat] a. Discuss the time management strategies with the nurses b. Review facility policies for taking scheduled breaks c. Provide coverage for the nurses' breaks d. Determine the reasons the nurses are taking scheduled breaks
d. Determine the reasons the nurses are taking scheduled breaks
22. A nurse is working on a quality improvement team that is assessing an increase in client fall at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? a. Notify staff of the increased fall rate b. Review current literature regarding client falls c. Implement a fall prevention plan d. Identify clients who are at risk of falls
d. Identify clients who are at risk of falls
18. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following members of the interprofessional team should the nurse consult? a. Risk management coordinator b. Clinical pharmacist c. Nursing supervisor d. Infection control nurse
d. Infection control nurse
44. A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? a. Raise all four side rails on the client's bed b. Remove the clock and calendar from the client's room c. Obtain a prescription for a sedative for the client d. Provide distractions for the client during the day
d. Provide distractions for the client during the day
41. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? a. The steps to follow when providing wound care b. The client's preferred time for bathing c. The belief that the client has a difficult relationship with his son d. The time the client received his last dose of pain medication
d. The time the client received his last dose of pain medication
20. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery. c. Ask the anesthesiologist to sign the consent. d. Transport the client to the operating room without verifying informed consent
d. Transport the client to the operating room without verifying informed consent
28. A charge nurse is observing a newly licensed nurse provide care for a client who has Clostridium difficile infections. Which of the following actions by the newly licensed nurse indicate an understanding of proper infection control procedures? a. Applies a mask before entering the client's room (It's contact precaution) b. Removes fresh flowers from the client's room. c. Washes her hands with an alcohol-based hand rub after caring for the client.(no, ineffective and must wash hands with soap/water) d. Wears gown when caring for client
d. Wears gown when caring for client