QBank 1 - Mgmt of Care

1

A client care team consists of a nurse, an LPN/LVN and an unlicensed assistive personnel (UAP). Which client will be assigned to the nurse? 1. Client diagnosed with toxic shock syndrome. 2. Client recovering from an ectopic pregnancy. 3. Client recovering from the removal of a hydatidiform mole. 4. Client recovering from a vaginal hysterectomy.

2

A client seeks emergency care for blood draining from the right ear after being in a motor vehicle crash (MVC). Which action will the nurse take first? 1. Notify the health care provider that the client 's condition could become critical. 2. Examine external ear for injuries. 3. Ask if the ear hurts. 4. Complete appropriate forms.

1 2 3 4

The nurse assigns a client who is receiving oxygen via a Venturi mask to the unlicensed assistive personnel (UAP). Which task can be delegated by the nurse to the UAP? (Select all that apply.) 1. Attach the client to the finger pulse oximeter. 2. Take the client's vital signs and record the results. 3. Report changes in the oxygen saturation to the nurse. 4. Place the call button within reach of the client. 5. Adjust the oxygen flow rate based on the client's need.

1 2 3

The nurse manager is informed that a client on the unit has developed a central line-associated bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an investigation of the incident. Which actions are appropriate for the nurse to take in this situation? (Select all that apply.) 1. Determine if lack of supplies was a contributing factor. 2. Review nursing documentation prior to the CLABSI. 3. Determine the method by which nurses access central lines. 4. Reassure the client and family that the CLABSI was unavoidable. 5. Instruct the nurses who cared for the client to obtain legal counsel.

1

The nurse notes that the output for a client diagnosed with chronic kidney disease was not documented for the previous shift. Which action will the nurse take first? 1. Call the assigned nurse and request the information. 2. Complete an incident report. 3. Ask the client to provide the amount of output. 4. Notify the immediate supervisor of the incident.

1

A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider? 1. A history of atrial fibrillation. 2. The client takes warfarin every day. 3. The blood glucose level is 200 mg/dL (11.1 mmol/L). 4. Lung sounds are diminished bilaterally at bases.

1

A school-age client with eye inflammation tells the school nurse that the parents refuse to take the student to a health care provider for medical attention. Which action will the nurse take first? 1. Discuss the condition of the child's eyes with the parents. 2. Notify the principal of the parents' refusal to seek health care. 3. Notify the child protective division of the department of human resources. 4. Cleanse the drainage from the child's eyes.

3

After receiving a report from the night nurse, which of the following clients should the nurse see FIRST? 1. A 31-year-old woman refusing sucralfate before breakfast 2. A 40-year-old man with left-sided weakness asking for assistance to the commode 3. A 52-year-old woman complaining of chills who is scheduled for a cholecystectomy 4. A 65-year-old man with a nasogastric tube who had a bowel resection yesterday

1

An older adult client diagnosed with type 1 diabetes mellitus (DM) relocates to a nursing facility, but neglects to bring all prescribed medication. Which response is the best for the nurse to make when the client says the missing medication relieves burning and stinging in the feet and legs? 1. "I will contact your health care provider to find out what medication you are taking." 2. "Can you describe the signs and symptoms to me?" 3. "Can you describe what the medication looks like?" 4. "Did the health care provider tell you what caused the burning and stinging?"

4

The charge nurse implements a change in the job description for an unlicensed assistive personnel (UAP). A staff nurse on the unit verbally agrees to the change, but behavior indicates that the staff nurse does not agree with the updated UAP job description. Which action by the charge nurse is best? 1. Tell the staff nurse that the witnessed behavior is unacceptable. 2. Schedule an appointment with the staff nurse. 3. Ask the UAP to accommodate the staff nurse. 4. Facilitate an open discussion during a prescheduled meeting with all staff nurses.

3

The charge nurse is making client assignments for the nursing team. Which client will the charge nurse assign to the LPN/LVN? 1. A client diagnosed with psychosis. 2. A client receiving chemotherapy. 3. A client in skin traction. 4. A client receiving a blood transfusion.

2

The family member of a client calls to ask the nurse to visit the client. The family member tells the nurse the client is refusing to seek medical attention for severe midsternal chest pain. Which activity will the nurse perform first? 1. Go to the client's home with a stethoscope and blood pressure cuff. 2. Contact the client and report being asked to visit by a family member. 3. Contact 911. 4. Ask the family member if there are color changes and dyspnea.

2

The nurse assesses a postoperative client. Which finding does the nurse document as subjective data? 1. Laboratory test results. 2. Client's description of pain. 3. Vital signs. 4. Electrocardiographic waveforms.

1 2 3 5

The nurse delivers a change-of-shift report. Which information is important for the nurse to include in the report? (Select all that apply.) 1. Client 's admitting diagnosis and relevant history. 2. Client 's emotional response to condition. 3. Current intravenous (IV) solution and flow rate. 4. Description of routine morning care provided. 5. Use of and response to as needed medications.

1 2 3

The nurse develops a brochure about informed consent. Which statement is appropriate for the nurse to include in the brochure? (Select all that apply.) 1. Written informed consent is needed when a client is having an invasive medical procedure. 2. Clients need to have all questions answered satisfactorily before signing a consent. 3. Emancipated minors may sign their own consents. 4. Obtaining a client's informed consent is a nurse's responsibility. 5. Mentally ill clients do not retain the right to refuse treatment.

4

The nurse educator prepares a class on crisis management. Which principle is most important for the nurse to emphasize when teaching this class? 1. The most charismatic person should assume leadership during a crisis. 2. During a crisis, leadership should be equally shared by the team members. 3. A well-prepared team does not require leadership during a crisis. 4. One person should be in charge during a crisis.

2

The nurse in the outpatient surgery center provides care for a client scheduled for an appendectomy. The client is expected in the operating room in 15 minutes. Which is the priority action for the nurse to implement with this client? 1. Perform preoperative teaching about having an appendectomy. 2. Check that the consent form is signed and attached to the medical record. 3. Perform a pre-operative shave and scrub with antibacterial soap. 4. Ask the client about allergies to food, medication, and other sources.

4

The nurse makes rounds on the medical unit to assess the care given by the unlicensed assistive personnel (UAP). Which observation requires an intervention by the nurse? 1. The UAP places the fingers of one hand on the wrist of a client in order to evaluate the respirations. 2. The UAP prepares to take a blood pressure in the left arm of a client recovering from a right mastectomy. 3. The UAP weighs a client on a standing scale while the client is balanced on crutches. 4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.

2

The nurse manager makes decisions for the group, gives orders, and is concerned with task accomplishments. Which leadership style does the nurse manager use? 1. Democratic leadership. 2. Autocratic leadership. 3. Laissez-faire leadership. 4. Transformational leadership.

2 3 4 5

The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which elements required to be present in a malpractice case? (Select all that apply.) 1. Intention. 2. Injury. 3. Causation. 4. Duty. 5. Breach of duty.

4

The nurse plans home care visits for the day. Which client will the nurse see first? 1. Older adult client discharged yesterday following treatment with intravenous heparin for a deep vein thrombosis. 2. Older adult client being regulated on warfarin. 3. Older adult client discharged from the hospital 3 days ago with pneumonia. 4. Older adult client expectorating pink-tinged sputum after running out of prescribed diuretic medication.

4

The nurse provides care for a client who has undergone a right total knee replacement. Which assessment finding requires immediate intervention by the nurse? 1. The client 's temperature is 99.4 °F (37.4 °C). 2. The client 's heart rate is 58 beats/min and regular. 3. The client 's pedal pulses are palpable, but weak bilaterally. 4. The client reports that the right calf is "cramping."

4

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first? 1. A client reports a headache unrelieved by extra-strength acetaminophen doses every 4 hours for 2 days. 2. A client reports ankle pain, swelling, and warmth. The client states there is no injury to the ankle. 3. The parent of a toddler calls to report that their child has a rash and sore throat. 4. The parent of a toddler calls to report that their child swallowed a nickel.

1

The nurse provides care for clients on the medical and surgical unit. Which situation requires immediate intervention by the nurse? 1. A client who had a liver biopsy is resting quietly on his back after the procedure. 2. A visitor is sitting without a mask just inside the doorway of a client on droplet precautions. 3. A client who had a cholecystectomy 2 days ago is draining purulent fluid through the T-tube. 4. A client scheduled for a cardiac catheterization is expressing anxiety and reservations about undergoing the procedure.

4

The nurse provides care for clients on the medical-surgical unit. After receiving report, which client does the nurse assess first? 1. A client admitted 8 hours ago with viral gastroenteritis who is complaining of nausea, vomiting, and diarrhea. 2. A client 24 hours post-thyroidectomy who is complaining of a headache and pain at the incision site. 3. A client admitted 3 days ago for chronic kidney disease with a urinary output of 220 mL in 8 hours. 4. A client admitted yesterday for heart failure and digitalis toxicity with frequent premature ventricular complexes.

2

The nurse provides care for several clients in a mental health care setting. Which situation requires the nurse's immediate attention? 1. Client with bipolar disorder walks into the day room wearing only underwear and begins dancing. 2. Client with depression says, "My plan is complete, and I'm ready to go for it." 3. Client recovering from substance abuse reports harassment by another client. 4. Client with schizophrenia says that it's "God's will" that the "evil television" be destroyed.

4

The nurse provides care to clients on the inpatient psychiatric unit. The nurse intervenes immediately with which client? 1. A client with borderline personality shouts, "I want my pain medication and I want it now!" 2. A client with anorexia nervosa is seen putting food from the tray into a pocket. 3. A client with postpartum depression states, "I cannot wait to get home and be with my baby." 4. A client with paranoid schizophrenia is pacing the hall at an increasingly rapid rate.

2 4

The nurse receives a report from the laboratory that a client 's sputum culture grew acid fast bacillus. Which transmission-based measures are appropriate for the nurse to implement? (Select all that apply.) - *Answer w/o commas between #s 1. Wearing a surgical mask to enter the client 's room. 2. Placing the client in an airborne infection isolation room (AIIR). 3. Putting an N95 respirator mask on the client during transport. 4. Adjusting the mask edge to fit under eyeglasses, if needed. 5. Wearing an impermeable gown to enter the client 's room.

3

The nurse receives report about four pregnant clients in active labor. Which client does the nurse assess first? 1. The nullipara client with cervical dilation of 10 cm and 100% effaced. 2. The nullipara client with fetus in transverse lie and baseline fetal heart rate of 155 beats per minute. 3. The multipara client with cervical dilation of 8 cm with the presenting fetal part at +2 station. 4. The multipara client with fetus in a frank breech presentation and presenting part at 0 station.

4

The nurse returns to the desk in the prenatal clinic and finds four phone messages. Which message does the nurse return first? 1. A multigravida at 12 weeks' gestation experiencing heavy white vaginal discharge. 2. A primigravida at 17 weeks' gestation stating that she has not felt the baby move. 3. A primigravida at 22 weeks' gestation reporting feeling dizzy and clammy when lying on her back. 4. A multigravida at 32 weeks' gestation experiencing malaise and bilateral dependent and facial edema.

4

The nurse reviews the medical records for clients arriving at the community clinic for care. Which client does the nurse identify as requiring immediate intervention? 1. A client whose fourth and fifth fingers are contracted onto the palm. 2. A client reporting numbness, tingling, and pain when the inside of the wrist is lightly tapped. 3. A client whose fingers hurt and turn from white to blue to red in cold weather. 4. A client in an arm cast with contracted fingers and wrist.

2 3 4

The nurse supervises care provided by an unlicensed assistive personnel (UAP). Which action by the UAP requires an intervention by the nurse? (Select all that apply.) 1. The UAP applies nonsterile gloves to empty a client's urostomy bag. 2. The UAP applies elastic compression stockings to a client after the client returns to bed after breakfast. 3. The UAP assists a 418.8 lb (190 kg) client diagnosed with lower extremity weakness to the bathroom. 4. The UAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. 5. The UAP documents morning vital signs and blood glucose levels obtained from a group of clients.

4

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first? 1. A 3-year old with a fever, an earache, and vomiting since yesterday. 2. A 5-year old reporting leg and arm pain after falling from a treehouse. 3. A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain. 4. A 40-year old who reports nausea, general anxiety, and is diaphoretic.

3

Which nursing action would likely be considered negligence? 1. The nurse does not aspirate before injecting a client's subcutaneous heparin. 2. The nurse removes a client's wrist restraints hourly to conduct a skin assessment. 3. The nurse assesses pedal pulses every 4 hours for a client who just returned from having a cardiac catheterization. 4. The nurse administers a preoperative client's prescribed sedative medication without removing the client's dentures.