professional development NCLEX

A nurse manager asks a licensed practical nurse to work on her day off because of a short staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. The assertive response by the licensed practical nurse to the nurse manager is which of the following?

"I have planned to take the day off and will not be able to work on that day."

A nurse asks a nursing student to describe case management. Which response by the student indicates a lack of understanding about this concept?

"It represents a primary health prevention focus managed by a single case manager."

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

*"Beneficiaries are limited to those providers that are participating health care providers for any required health care services."* Options 1, 2, and 3 are accurate descriptions of the preferred provider organization. In the exclusive provider organization, beneficiaries are limited to those providers that are participating health care providers for any required health care services. If members elect to see health care providers outside the exclusive provider organization, services may not be covered.

A nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action?

*Decline to sign the will.* Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care.

A nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

*The tertiary level of prevention* Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on seeking to detect existing health problems or trends and reducing the intensity and duration of the crisis during the crisis itself. There is no known aggregate care prevention level.

A licensed practical nurse (LPN) asks a nursing assistant to gather supplies in preparation for administering a tepid bath to a child with a fever. The LPN intervenes if the nursing assistant obtains which unnecessary item(s)?

A bottle of alcohol

A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

A nurse responds to an external disaster that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim will the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the nursing assistant?

Answering the call light promptly after the enema has been given

A nurse is recording an end-of-shift report for a client. What information needs to be included?

As-needed medications given that shift

A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following?

Call the nursing supervisor.

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after the delegation of the tasks is to:

Perform follow up with each staff member regarding the performance of the task and the outcomes related to the implementation of the task.

A client has just been treated with cardioversion. The nurse should assess which first?

Status of airway

A nurse is observing a nursing assistant communicating with a client who is deaf. The nurse would intervene if which of the following behaviors is observed?

The nursing assistant stresses words by over-enunciating them when speaking.

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this client?

Obtain telephone consent from the family member witnessed by two persons.

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds by telling the nurse educator that it:

Outlines what the organization plans to accomplish

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN suggests which of the following to the community nurse to direct the group most effectively?

Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

Private room within sight of the nurses' station

A nurse observes that a client received pain medication 1 hour ago from another nurse but the client still has severe pain. The nurse has previously observed this same occurrence. On the basis of the nurse practice act, the observing nurse plans to do which of the following?

Report the information to a nursing supervisor.

A nurse suspects that a co-worker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to a supervisor.

A nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Respiratory status

After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?

The state convicts the nurse for invasion of privacy.

A client receives meperidine (Demerol) by the intramuscular route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the health care provider. The nurse completes an incident report and accurately documents which of the following?

Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the health care provider was notified.

A nurse is completing a medication reconciliation form for a client. Which of the following is a primary purpose of this process?

To compare a client's medication prescriptions to all of the medications the client is taking at home

A nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. The appropriate nursing response to the client is:

"A nurse caring for a client cannot serve as a witness to a living will."

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated."

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which of the following is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who says that voices sponsored by the FBI are telling him to stab his roommates

A nurse on the day shift receives client assignments for the day. Which assigned client should the nurse assess first?

A client who was admitted during the night because of a severe exacerbation of asthma

A licensed practical nurse (LPN) has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

A client with a fever who is diaphoretic and restless

A licensed practical nurse (LPN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The LPN must assign four clients and has another LPN and three nursing assistants on a nursing team. To which of the following clients should the nurse assign the LPN?

A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

A nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies the client needs that are the priority by telling the nursing instructor that:

Actual or life-threatening concerns are the priority.

A nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. The initial action by the nurse who observed the error is which of the following?

Ask the nurse if he or she intends to report the error.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following?

"I will call the nursing supervisor to seek assistance regarding your request."

A nursing graduate is employed as a licensed practical nurse (LPN) in a local hospital. During orientation, the nurse educator asks the LPN about her understanding of the need to obtain professional liability insurance. The appropriate response by the LPN is:

"Nurses are encouraged to have their own malpractice insurance."

A new nurse graduate asks another nurse about the need to obtain professional liability insurance. The appropriate response by the nurse is:

"Nurses need to have their own malpractice insurance."

A nursing instructor asks a nursing student to define a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths?

"They are nursing care plans and use the steps of the nursing process."

A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place the highest priority on which ongoing nursing interventions?

*Monitoring of the status of both mother and fetus* All of the options represent correct nursing actions, but the highest priority is to monitor the status of the mother and fetus. This option is the one that exemplifies the most urgent physiological need and, as such, takes precedence over the other nursing interventions.

A nurse is planning the client assignments for the shift. Which of the following clients should the nurse assign to the nursing assistant?

A client requiring frequent ambulation with a walker

A nurse has received a 7 AM change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

A nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for evidence of which of the following that supports that this in fact has occurred?

A judicial decision in a court of law

A nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?

A postoperative client who develops a cough and a fever

A nurse is assisting in planning the client assignments. Which of the following is the least appropriate assignment for the nursing assistant?

Assisting a profoundly developmentally disabled child to eat lunch

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

A nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to a nursing assistant to attend to the other clients and tells another nurse to call the health care provider immediately. In this situation, the nurse is implementing what leadership style?

Autocratic

A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. In formulating a response, the nurse understands that this is being done to:

Avoid a conflict of interest by the team evaluating the recipient and the team evaluating the donor.

A client is brought to the emergency department and is unconscious. From the viewpoint of informed consent, a nurse determines that emergency treatment can be initiated to the unconscious client:

Because emergency treatment can be provided under the emergency doctrine

A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 AM. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 AM and is due to eat lunch at noon. Arrange, in order of priority, the actions that the nurse would take.

Check the client's blood glucose level. Give the client half a cup of fruit juice to drink. Take the client's vital signs. Retest the client's blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, the actions taken, and the outcome.

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

A nursing assistant who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The nursing assistant's lateness has caused unrest with other staff members in the nursing unit. The nursing assistant is due to receive a 3-month probation evaluation in 1 month. The nurse in charge of the nursing unit should appropriately deal with this situation by:

Confronting the nursing assistant to discuss the lateness and initiate problem-solving measures

A nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking prior to admission. The appropriate nursing action is to:

Consult with the registered nurse (RN).

A nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription and asks the health care provider to prescribe a dosage within the recommended range. The health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which of the following actions should the nurse take?

Contact the nursing supervisor.

A nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is:

Defined as the failure to meet established standards of care

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

A nurse is providing instructions to the nursing assistant who will be caring for a client with security devices (hand restraints). The nurse instructs the nursing assistant to check the client's skin and circulation under the security devices:

Every 30 minutes

A nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which of the following is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

A licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that the initial step in the process of change is which of the following?

Identify the inefficiency that needs improvement or correction.

A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by a nursing assistant. The nurse observes the nursing assistant care for the client and intervenes if the nursing assistant:

Lets the drainage tubing rest under the leg

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). After appropriately charting in the medication administration record, the nurse should:

Make a notation regarding the client's refusal in the nurse's notes.

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which of the following represents the legal ramifications associated with the RN's behavior?

No charge will be made against the RN, because the RN's actions are reasonable.

A client tells the nurse about his decision to refuse external cardiac massage. Which of the following would be the appropriate initial nursing action?

Notify the health care provider of the client's request.

A nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client that the results have not returned, when in fact the health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement?

Slander

A nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse implements which of the following?

Stay with the client and consult with the nurse manager about the situation.

The nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which of the following is the best nursing intervention for this situation?

Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center.

A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

Taking photographs of the client without consent

A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement, if made by the student, would indicate a need for further study of the levels of prevention?

Teaching a stroke client how to use a walker

A nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which of the following accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will protect the nurse if the care given at the scene was not negligent.

A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which of the following?

The client cannot be forced to take the medication unless the client has been legally deemed incompetent and legal guardianship is obtained and the guardian authorizes administration of the medication.

A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which of the following concepts?

The client's right to autonomy and the nurse's obligation to behave ethically

A nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to a nursing assistant. The nursing assistant notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which of the following is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the health care provider.

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?

Transport the client to the operating room immediately.

An adult client is brought to the emergency department by the emergency medical services team after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. With regard to informed consent for the surgical procedure, which of the following is the best initial action?

Transport the victim to the operating room for surgery.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Use of padded restraints to immobilize the limb

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider that the client had terminal cancer. The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

"I will contact the medical examiner regarding your request."

A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply.

*2. Increased risk of hypotension* *3. Failure to teach the client adequately* *4. Increased need to protect the client* *6. Lack of follow-up nursing actions* To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which does the nurse use to determine if the autopsy can proceed?

*Determination by the client's son* The nurse works with the client's son to determine if an autopsy can be performed (option 2) because the only powers that supersede an offspring's decision are the client's written statement, a durable power of attorney, or a surviving spouse. In order, a parent, brother, or sister can make the decision if the client has no children. A client's will involves bequeathing property and does not contain information about medical care (option 1). The client's sibling is consulted after an offspring (option 3). The client's death is unlikely to be a medical examiner's case or a suspicious death, so a medical examiner's ruling is not indicated.

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. What is the best initial action?

*Determine if the pain is cardiac in origin.* The best initial action is to rule out chest pain of cardiac origin to eliminate a cardiovascular etiology related to the client's complaint. If the pain is left untreated and the pain is caused by myocardial ischemia or infarction (MI), the client could suffer a devastating cardiac injury. Furthermore, the nurse does this because a female presenting with an MI is more likely to display atypical clinical indicators, including fatigue and dyspnea. After instituting measures to rule out a cardiac problem, the nurse completes the client assessment by auscultating the heart and lungs and by reviewing the medical record. After a cardiac problem is ruled out, the nurse can administer an analgesic if prescribed.

A nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care prior to transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which of the following is accurate regarding the nurse's immunity from this suit?

A Good Samaritan law will protect the nurse.

A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?

A client on a ventilator

A nurse in charge of a rehabilitation center is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?

A client on strict bedrest and a 24-hour urine collection

A nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

An experienced postpartum nurse has received report on four clients. Which client should the nurse most appropriately assign to another licensed practical nurse (LPN)?

A client recovering from a scheduled cesarean delivery

A licensed practical nurse (LPN) is planning the client assignments for the day. Which of the following is an appropriate assignment for the nursing assistant?

A client who requires a 24-hour urine collection

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which of the following victims should be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing

A nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which of the following actions?

Ask the nurse manager of the neurological unit to discuss the assignment.

A nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. The nurse should appropriately manage this concern by:

Discouraging the racial comments

A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. Arrange the order in which the nurse would implement the prescriptions.

High-Fowler's position O2 via nasal cannula at 2 L/min Erythromycin ethylsuccinate (EryPed) chewable tablets 200 mg orally every 6 hours Chest x-ray Clear liquids PO as tolerated

A nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which of the following is a characteristic of this type of nursing model practice?

Nursing personnel are led by an RN leader in providing care to a group of clients.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is very sedated. The LPN understands that which of the following is the appropriate action?

Obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons

A nurse is present at a disaster scene and is participating in the triage of victims. What color tag should be assigned to a victim with evidence of open pneumothorax?

Red

Which of the following is a recommended guideline for safe computerized charting?

Report accidental deletions from the computerized file to the nursing manager or supervisor.

A nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the children. The nurse has never worked in the pediatric unit. Which of the following is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse, knowing that which of the following is necessary?

Reporting the case to legal authorities

A nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." The appropriate nursing action is to:

Tell the client that it is necessary to notify the health care provider of the client's request.

A nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that in this position of authority, authority appropriately refers to:

The official power to approve an action, command an action, or to see that a decision is enforced

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks the nurse if this document is still effective. The appropriate nursing response is which of the following?

*"A living will needs to be reviewed yearly with your health care provider."* The client should discuss the living will with the health care provider, and it should be reviewed annually to ensure that it contains the client's present wishes and desires. Options 1 and 4 are inaccurate. Option 2 is not the most appropriate response.

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

*"They are specific guidelines."* Standards of care are authoritative statements that describe a common or acceptable level of client care or performance that have some similarity to policies and procedures. Thus, standards of care define professional practice. The American Nurses Association has formulated general standards and guidelines for nursing practice. They are broad and general in nature and apply across the nation.

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

*1. Administering oxygen* *2. Inserting a Foley catheter* *3. Administering furosemide (Lasix)* *4. Administering morphine sulfate intravenously* Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A nurse enters a client's room and finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report, understanding that it allows for the analysis of adverse client events through:

*A method of promoting quality care and risk management* Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present. Options 1, 3, and 4 are incorrect.

A client arrives in the emergency department and is staggering, confused, and verbally abusive. The client complains of a headache from drinking alcohol and is asking for medication. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With which of the following can the client legally charge the nurse as a result of the nursing action?

*Assault* An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. When the individual's private affairs are unreasonably intruded upon, invasion of privacy occurs.

A nurse is planning the client assignments. Which of the following is the least appropriate assignment for the nursing assistant?

*Assist a child who is profoundly developmentally disabled to eat lunch.* The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for the nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore has a higher potential for complications, such as choking and aspiration. The remaining options do not include data indicating that these tasks carry any unforeseen risk.

The nurse on the day shift is assigned to care for the following six clients. Arrange in order of priority how the nurse would plan to check the assigned clients.

*Client who has a tracheostomy and is on a mechanical ventilator* *Client who requires before-breakfast insulin* *Client who is scheduled for a cardiac catheterization at 9:00 AM* *Client who requires medications at 10:00 AM* *Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home* *Client who is scheduled for physical therapy in the afternoon* The airway is always a high priority, and the nurse first assesses the client who has a tracheostomy and is on a mechanical ventilator. The remaining order of priority is guided by time guidelines. Therefore, the nurse next administers before-breakfast insulin, assesses the client who is scheduled for a cardiac catheterization at 9:00 AM, and then administers medications scheduled for 10:00 AM. Finally, the nurse checks the client who is scheduled for discharge, and this is followed by checking the client who is scheduled for physical therapy in the afternoon.

A nurse employed in a long-term care facility calls the health care provider (HCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which of the following actions should the nurse take?

*Contact the nursing supervisor.* If the HCP writes a prescription that requires clarification, it is the nurse's responsibility to contact the HCP for clarification. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until clarification has been obtained.

A nurse is giving a bed bath to an assigned client. A nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which of the following?

*Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.* The nurse is responsible for the care provided to the assigned clients. The most appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 4 is not a responsibility of the nursing assistant.

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. The nurse informs the client that the initial step in preparing this document is to:

*Discuss the request with the health care provider.* The client should discuss the request for a living will with the health care provider. The client should also discuss this desire with the family, although in this situation, based on the client's feelings, talking to the family would be the second step. Wills should be prepared with legal counsel and should identify the executor of the estate, address distribution and use of property, and specific plans for burial. Although option 1 may be helpful, this contact would not be the initial step. The lawyer would be contacted following discussion with the health care provider and family.

A licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. The LPN calls the registered nurse who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report and the nursing supervisor and health care provider (HCP) are notified of the incident. Which of the following is the next nursing action regarding the incident?

*Document a complete entry in the client's record concerning the incident.* The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

A nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?

*Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry.* The placement of an NG feeding tube is checked at least every 4 hours for residual during administration of continuous tube feedings. Placement is also checked before each bolus with intermittent feedings and before the administration of medications through the tube. The bag and tubing are completely changed every 24 hours or per agency protocol. The hanging bag should be rinsed before new formula is added to it. An excess amount of feeding should not be allowed to sit in the feeding bag because of the potential for the growth of bacteria.

A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?

*Nursing staff are led by a nurse when providing care to a group of clients.* In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

A nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which of the following would be a primary prevention intervention that the nurse could suggest to use?

*Providing educational programs, literature, and posters to promote awareness of healthy eating* Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring. Options 1, 2, and 4 are secondary prevention measures that seek to detect existing health problems or trends.

A nurse calls the health care provider (HCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the HCP. The HCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the HCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse plans to address the HCP's remark, understanding that the HCP has violated which legal tort?

*Slander* Defamation is a false communication or careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action?

*Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent.* Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

A nurse is documenting information regarding a client's care into the computerized medical record. Which of the following actions by the nurse would be appropriate? Select all that apply.

1. Change the password for entering computer files at least monthly. 2. Shred the printout of the nurse's flowchart at the end of the nurse's shift. 3. Use own user name and password when logging into the computer system.

Choose the correct guidelines related to narrative documentation. Select all that apply.

1. Date and time entries. 2. Sign and title each entry. 4. Avoid judgmental and evaluative statements. 6. Do not leave blank spaces on documentation forms.

A nurse employed in a long-term care facility is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant?

A client who requires a 24-hour urine collection

A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

A client who requires frequent ambulation

A client working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client would the nurse collect data on first?

A client who was complaining of severe back pain on the previous shift

A client had a colon resection. A Salem tube was in place when a regular diet was brought into the client's room. The client did not want to eat solid food and asked that the health care provider be called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two meals and subsequently had additional surgery due to complications. The nurse understands that the determination of negligence in this situation is based on:

A duty existed and it was breached

A nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in:

A few individuals such as the board of directors

A nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. Which of the following can the client legally charge the nurse as a result of the nursing action?

Battery

A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train accident. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

Discuss her anxieties and concerns with the nursing supervisor about floating.

A vascular surgeon repeatedly asks a nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains these reasons to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse would appropriately manage this situation by:

Discussing the situation with the nurse manager

A nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline (Zoloft), on the bed. Which of the following assessments has priority?

Respirations

A nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate a negative variance?

The presence of dysrhythmias in a client with a myocardial infarction

A nurse observes an outburst by a client with a history of schizophrenia, during which the client used extreme foul language. The nurse appropriately documents this occurrence by:

Using quotation marks, exact words, and additional objective information about affect and nonverbal behavior