RN 2.0-Elsevier Adaptive Quizzing-HESI Prep

Under a leader, a team of followers has failed to achieve success in conducting research. What does an effective leader do in this situation? a. Criticizes the team members for failure b. Provides excuses for the negative outcome c. Refuses to take the responsibility for failure d. Accepts failure and gains experience from it

d. Accepts failure and gains experience from it *An effective leader should accept the failure and gain experience from it to avoid repetition of the same errors. *The effective leader should counsel and motivate the team members for future success and should not criticize them. Making excuses for the negative outcome is not the correct action of the effective leader. The effective leader should take responsibility for the failure and the growth he or she will gain from it.

Which component of delegation is retained while the delegator is delegating the client's care task to the nursing aide? a. Authority b. Supervision c. Responsibility d. Accountability

d. Accountability *Accountability is retained by the delegator while delegating a client's care task to the nursing aide.* Every individual on the healthcare team has authority for the delegated task. The nursing aide is just responsible for the delegated task, so the delegator retains the accountability. Supervision is a right of delegation.

A client who sustained a leg fracture is prescribed intramuscular analgesic medication. Which healthcare professional can be safely delegated this task? a. Registered nurse (RN) b. Patient care associate (PCA) c. Licensed practical nurse (LPN) d. Unlicensed nursing practitioner (UNP)

c. Licensed practical nurse (LPN) *An LPN is authorized to administer oral and intramuscular drugs.* An RN is a delegator, who can administer intravenous drugs. PCAs and UNPs are unlicensed personnel who can perform tasks such as positioning the client and maintaining the hygiene of the client.

Which topic is most important for the nurse to teach in a community health promotion class of middle-aged adults? a. Cessation of smoking b. Prevention of infection c. Abstinence from alcohol d. Decreasing high-density lipoproteins (HDL) levels

a. Cessation of smoking Smoking is a major risk factor for cardiovascular disease and hypertension which are major health problems of middle-aged adults. Middle-aged adults are not at greater risk for infection. Alcohol intake should be limited, but abstinence is not required for prevention of health problems. High density lipoprotein (HDL) levels should be increased to help prevent cardiovascular disease.

When caring for a transgender client, which would the nurse use to decide how to address the client? a. Client's preference b. Client's appearance c. Client's clothing d. Client's identity document (e.g., birth certificate)

a. Client's preference The nurse should ask the client during assessment how the client prefers to be addressed. This prevents any discomfort or embarrassment. The nurse should not make assumptions based on the client's appearance, which can be misleading. The nurse should also not address the client according to his or her identity documents, because they may contain the client's natal information, which might not be how the client self-identifies.

A nurse leader has prepared an objective for strategic planning. Which point indicates that the nurse possesses the ability to write objectives clearly and concisely? a. Inclusion of the timeline and deadline b. Leaving expectations open to interpretation c. Starting with an article followed by a noun d. Specifying multiple dates for the attainment of a goal

a. Inclusion of the timeline and deadline *In order for objectives to be clear and concise, they should have a timeframe within which the activity or improvement must be achieved. The timeline and deadlines should be included in the written objective. * A clear and concise objective should leave no question about the expectations; it should not be open to interpretation. An objective should always start with "to" followed by an action verb. A single date for attaining the goal is the indication of a clear and concise objective

The nurse is getting ready to perform an initial assessment interview of a Chinese older adult who does not speak English. The client has a tibial fracture and is hard of hearing. Which should be available before starting the interview in order to minimize communication problems that may lead to health disparity? a. Wheelchair and hearing aid b. Hearing aid and interpreter c. Interpreter and sphygmomanometer d. Wheelchair and sphygmomanometer

b. Hearing aid and interpreter In order to minimize communication problems leading to health disparities between the client and the nurse, a hearing aid and an interpreter should be available. A client with a broken leg will have limited mobility and may need a wheelchair, but this has no role in eliminating communication barriers. A sphygmomanometer is required to measure blood pressure, but it will not improve communication.

What are the clinical manifestations of myocardial infarction in women? Select all that apply. a. Anoxia b. Indigestion c. Unusual fatigue d. Sleep disturbances e. Tightness of the chest

b. Indigestion c. Unusual fatigue d. Sleep disturbances Indigestion, unusual fatigue, and sleep disturbances are clinical manifestations of myocardial infarction in women. Anoxia and tightness of the chest are clinical manifestations of angina pectoris, not myocardial infarction

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? a. Constipation b. Muscle spasms c. Hypoactive reflexes d. Increased specific gravity

b. Muscle spasms Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia. Hypoactive reflexes are signs of hypercalcemia. Increased specific gravity is a sign of fluid volume deficit.

What is the ultimate goal of delegation? a. To deliver patient care as a team b. To maximize patient care outcomes c. To improve the working ability of the nurse d. To maintain open lines of communication between delegator and the delegate

b. To maximize patient care outcomes *The ultimate goal of the delegation is to maximize patient care outcomes.* Delegation helps to deliver patient care as a team and improves the working ability of the nurse but these are not the ultimate goals of delegation. Maintaining open lines of communication between delegator and the delegatee creates a productive work environment in delivering patient care.

A client who has gastroesophageal reflux disease (GERD) is unable to tolerate a back rest elevation. The nurse should place the client in what position in the illustration? a. a b. b c. c d. d

d. d i. The reverse Trendelenburg position uses gravity to help keep gastric contents in the stomach, thereby minimizing reflux of gastric contents into the esophagus. The high-Fowler and the semi-Fowler position would not be tolerated by the patient. The flat position may permit the flow of gastric contents through the cardiac sphincter into the esophagus, contributing to GERD and increasing the risk of aspiration.

Which team member is most accountable when delegating a task to the healthcare team? a. Certified technician b. Registered nurse (RN) c. Licensed practical nurse (LPN) d. Unlicensed assistive personnel (UAP)

b. Registered nurse (RN) *The registered nurse (RN) on the healthcare team is most accountable when delegating a task to the team. *The certified technician on the healthcare team is responsible for the assigned task. Similarly, the LPN and UAP are also responsible for the assigned task.

What factors are most important for the nurse to consider when delegating responsibilities? a. Preferences of the clients and staff b. Physical layout of the unit and client rooms c. Staff member's level of education and expertise d. Client's diagnosis and length of time in the hospital

c. Staff member's level of education and expertise Delegation should provide for client safety based on staff capabilities as determined by level of education and experience. Although client and staff preferences may be considered, they are not the most important criteria for determining delegation of tasks. Although geographic factors may be considered when tasks are delegated, these are not the most significant criteria to consider. The client's acuity, not diagnosis or length of time in the hospital, is the most important client factor to consider when appropriate staff members are assigned to provide care.

A 19-year-old woman, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client's lack of remorse and repetitive behavior probably are related to what underdeveloped aspect of personality? a. Id b. Ego c. Superego d. Limbic system

c. Superego Lack of remorse indicates a weak superego, the aspect of personality concerned with prohibitions. The id is not underdeveloped in this person; the id acts to achieve self-gratification. The ego is not related to acting-out behavior. The limbic system is not underdeveloped; it is related to the achievement of pleasure.

The nurse is an active participant on human resource committees. What does this indicate? a. The nurse is engaging in malpractice. b. The nurse is pursuing higher education. c. The nurse is staying clear on group outcomes. d. The nurse is thinking only about personal needs.

c. The nurse is staying clear on group outcomes. *When a nurse participates as a leader in any leadership opportunities such as on human resource committees, it indicates that he or she is staying clear on group outcomes.* Participating on human resource committees does not indicate any involvement in malpractice. Active participation on human resource committees does not indicate pursuing a higher degree. Participating on human resource committees indicates that the nurse is thinking beyond his or her personal needs

The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility

a. Advocating on behalf of the client *The public depends on the nurse leaders to move forward the consumer advocacy agenda. Therefore as a leader, the nurse should advocate on behalf of the client.* Discussing the client's problem with another nurse does not indicate leadership quality. Arranging a permanent accommodation and suggesting long-term healthcare facility for the client does not indicate leadership; instead it keeps the client in emotional distress.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? a. Ammonia level b. Culture and sensitivity c. White blood cell count d. Alanine aminotransferase (ALT) level

a. Ammonia level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.

17. What is the status of the unit secretary as a member of the healthcare team, which is in the span of control of a registered nurse (RN)? a. Devoid of legal authority b. Answerable to the nurse manager c. Answerable to the registered nurse d. Devoid of performing non-medical tasks

a. Devoid of legal authority *A unit secretary is a member of the healthcare team who is devoid of formal preparation or legal recognition.* RNs or healthcare providers who report to a designated delegator, such as a nurse manager, are answerable to the nurse manager. Members with dependent status such as unlicensed assistive personnel (UAP) and the licensed practical nurse (LPN) and licensed vocational nurse (LVN) who function under the direction of an RN or physician are answerable to the RN. The unit secretary's role in the healthcare team is to perform nonmedical tasks.

Who is accountable for the ongoing evaluation of a client's care? a. Registered nurse (RN) b. Chief nursing officer (CNO) c. Licensed practical nurse (LPN) d. Unlicensed nursing personnel (UNP)

a. Registered nurse (RN) *Registered nurses are accountable for the initial assessment and the ongoing evaluation of a client's care.* CNOs are accountable for establishing systems to communicate competency requirements related to delegation. The LPN directly provides care to the client. UNPs provide client care under the supervision of a registered nurse.

The nurse is overseeing a nursing student who is conducting an assessment of a client who does not speak English. No interpreter is available. Which action requires further teaching? a. Using medical terminology b. Proceeding in an unhurried manner c. Speaking in a low and moderate voice d. Pantomiming words and simple actions while verbalizing them

a. Using medical terminology Nurses should follow certain guidelines when interpreter is not available while assessing a client who does not understand English. Rather than using medical terminology, the nursing student should use simple, more well-known words, like "pain" instead of "discomfort." The nursing student's other actions are appropriate. Proceeding in an unhurried manner; speaking in a low, moderate voice; and pantomiming words and simple actions while verbalizing them promote effective communication.

The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse? a. "Touch the tick with a lit cigarette." b. "Remove the tick carefully with tweezers." c. "Pour ammonia over the tick, and it will shrivel up." d. "Spray the tick with insect repellent, and it will fall off."

b. "Remove the tick carefully with tweezers." The tick must be carefully removed with tweezers or forceps so the body and head are both removed; this technique prevents further inoculation of the individual. Using a lit cigarette, ammonia, or insect repellent is unsafe; the tick may further inoculate the child, and the method may hurt the child.

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. a. Goggles b. Surgical mask c. Shoe covers d. Gown e. Gloves f. N95 hepa mask

b. Surgical mask d. Gown e. Gloves A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside.

A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? a. Administering analgesics b. Administering intravenous antibiotics c. Administering nerve block anesthesia d. Administering mouth wash for oral hygiene

d. Administering mouth wash for oral hygiene *The UAP scope of practice includes administering mouth wash to the client.* Instructing the UAP to administer medications such as antibiotics and anesthetics is inappropriate because the UAP is not eligible to do so and may not have the knowledge to administer medications. Administering nerve block anesthesia should be performed by the anesthesiologist.

Which scenario is most likely to contribute to health disparities? a. An English-speaking critical care nurse assesses a Hispanic patient in a coma. b. An English-speaking nurse plans the nursing procedures for a black Latino patient. c. An English-speaking nurse provides discharge instructions to an English-speaking patient who is hard of hearing. d. An English-speaking nurse single-handedly conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

d. An English-speaking nurse single-handedly conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English. As per the U.S. Department of Health and Human Services Office of Minority Health, health care organizations should offer and provide language assistance services, including an interpreter, to each patient with limited English proficiency at all points of contact during all hours of operation and service. Therefore, presence of an interpreter is essential for the admission interview of a Puerto Rican immigrant with limited knowledge of English. A Hispanic patient in coma is not able to speak, so an interpreter is not necessary. Interpreter service is not required while the nurse plans nursing procedures because the nurse does not interact with the patient directly during this phase. Although the nurse must ensure that the hard-of-hearing patient can hear discharge instructions, there is lower risk for health disparities since the nurse and the patient speak the same language.

A client is being discharged after having a total thyroidectomy. Which instruction is most important for the nurse to include? a. Take thyroid replacement medications as prescribed. b. Be aware of signs and symptoms of dehydration. c. Avoid all over-the-counter medications. d. Report signs of hypoglycemia.

a. Take thyroid replacement medications as prescribed. Long-term thyroid replacement is prescribed after surgery to replace the thyroid's natural function. Although teaching signs and symptoms of dehydration is a health promotion strategy, it is not the priority. Clients should not be encouraged to avoid all over-the-counter medications, but they should be instructed to discuss contraindications with their primary healthcare provider or pharmacy. Low blood glucose is not attributed to this procedure.

Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply. a. Analyzing vital signs b. Maintaining oral hygiene c. Administering intravenous drugs d. Administering oral hypoglycemic agents e. Administering intramuscular medications

d. Administering oral hypoglycemic agents e. Administering intramuscular medications *Licensed vocational nurses and licensed practical nurses are authorized to administer drugs through oral and intramuscular routes.* Analyzing vital signs should be performed by the registered nurse. Hygiene maintenance can be delegated to unlicensed nursing practitioners (UNP). Administering intravenous drugs should be done by the registered nurse.

In a health care setting, there are a limited number of unlicensed nursing personnel. Who would take up the responsibility of delegation in place of the registered nurse? a. Charge nurse b. Chief nursing officer c. Patient care associate d. Licensed practical nurse

a. Charge nurse *Charge nurses act as delegators as they also have knowledge and expertise in the clinical setting. In cases where there are a limited number of unlicensed nursing personnel, the registered nurse does not delegate tasks. In this instance the charge nurse usually becomes a delegator and delegates the tasks.* The chief nursing officer is not the immediate person to delegate the tasks in such instances. Patient care associates and licensed practical nurses act as delegatees.

Which actions make the nurse a transformational leader? a. Gaining higher education degrees b. Introducing a vision for the future nurses c. Implementing client-centered care effectively d. Correcting errors of the followers in a reactive manner

b. Introducing a vision for the future nurses *A transformational leader creates and shares a vision or goal for future nurses. *Gaining higher education does not indicate leadership. Effective implementation of client-centered care indicates professionalism but not leadership. A transformational leader corrects the errors of followers by coaching and mentoring, not by using a reactive manner.

Who supervises unlicensed nursing personnel (UNPs) in providing care to the client? a. Charge nurse b. Nurse manager c. Registered nurse d. Patient care associate

c. Registered nurse *The registered nurse (RN) supervises UNPs and also licensed practical nurses (LPNs) in providing care to the client. *The charge nurse and the nurse manager may supervise RNs. The charge nurse delegates the tasks to the LPN and UNP when the RN does not delegate. The nursing manager is in charge of the RN, LPN, and UPN. The patient care associate does not supervise the UNPs and is delegated tasks by an RN.

A client was diagnosed with cancer of the head of the pancreas two months ago. The client is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the client's assessment, the nurse expects the client's stool to be what color? a. Green b. Brown c. Red-tinged d. Clay-colored

d. Clay-colored Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum. Green stools may occur with prolonged diarrhea associated with gastrointestinal inflammation. The feces are brown when there is unobstructed bile flow into the duodenum. Inflammation or ulceration of the lower intestinal mucosa results in blood-tinged stools.

A nurse is assigned to take care of a group of clients. Which client should the nurse see first? a. A 2-year-old client with diarrhea b. A 35-year-old client who is nauseated c. A 40-year-old client who has vomiting due to food poisoning d. An 83-year-old client whose last bowel movement was 3 days ago.

a. A 2-year-old client with diarrhea The 2-year-old child will be at higher risk for fluid and electrolyte imbalance due to higher fluid content of the body and decreased ability to regulate fluid balance, which put this client in a life-threatening situation. Care of the 35-year-old client with nausea is not a priority because the client's body has a higher ability to regulate fluid and electrolyte balance compared with the child. Care of the 83-year-old female having difficulty moving her bowels is not a nursing priority because it is not a life-threatening situation. Care of the 40-year-old female with vomiting is not a nursing priority because this client has a higher ability to regulate fluid and electrolyte balance compared with the child.

The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility

a. Advocating on behalf of the client The public depends on the nurse leaders to move forward the consumer advocacy agenda. Therefore as a leader, the nurse should advocate on behalf of the client. Discussing the client's problem with another nurse does not indicate leadership quality. Arranging a permanent accommodation and suggesting long-term healthcare facility for the client does not indicate leadership; instead it keeps the client in emotional distress.

When caring for a client with pneumonia, which nursing intervention is the highest priority? a. Increase fluid intake. b. Employ breathing exercises and controlled coughing. c. Ambulate as much as possible. d. Maintain a nothing-by-mouth (NPO) status.

b. Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? a. Avoid answering questions. b. Give the child a list of expectations. c. Be consistent about established rules. d. Allow the child to plan the day's activities.

c. Be consistent about established rules. Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

When assisting an older adult (ages 65 to 75 years) in successfully completing Erikson's task of this stage, the nurse should help the client with what task? a. Investing creative energies in promoting social welfare b. Redefining a role in society that offers something of value c. Look to recapturing those opportunities that were not experienced d. Feeling a sense of satisfaction when reflecting on past achievements

d. Feeling a sense of satisfaction when reflecting on past achievements Feeling a sense of satisfaction when reflecting on past achievements encourages the client to accept what life is or was and helps prevent feelings of despair. Although older adults may invest creative energies in promoting social welfare, it is not the task associated with Erikson's theory concerning older adults. According to Erikson's developmental theory, redefining a role in society is the task of young adults. Looking to recapture those opportunities that were not experienced is a desire that must come from the client.

Which activity performed by the registered nurse (RN) indicates effective delegation? a. Following one-way communication with the delegatee b. Assigning a task to a new licensed practical nurse(LPN) c. Providing feedback to the delegatee while performing the task d. Supervising and monitoring the licensed practical nurse (LPN) about the different activities

d. Supervising and monitoring the licensed practical nurse (LPN) about the different activities The delegator should supervise and monitor the delegatee when the work is being assigned to the delegatee. The communication between delegatee and delegator should always be two-way to get the expected outcome. The delegator should evaluate the ability of the delegatee and should supervise the different tasks before assigning the work to the new delegatee. The delegator should always provide feedback at the end of the task.

On which principle should the nurse's role be based in the maintenance or promotion of the health of older adults? a. There is a strong correlation between successful retirement and good health. b. Thoughts of impending death are common and depressing to most older adults. c. Some of the physiologic changes that occur as a result of aging are reversible. d. Older adults can better accept the dependent state that chronic illness often causes.

a. There is a strong correlation between successful retirement and good health. Individuals who can reflect on life and accept it for what it was and who are able to adjust and enjoy the changes retirement brings are less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? a. Treat all patients equitably and fairly. b. Act in ways to prevent harm to patients. c. Tell the patient the truth about their health. d. Help the patients to make informed choices.

b. Act in ways to prevent harm to patients. Nonmaleficence means to act in ways that prevent patient harm or even the risk of harm. Telling the truth to patients about their health refers to veracity. Helping patients make informed choices promotes autonomy. Justice involves treating all patients equitably and fairly.

A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup? a. Crash cart with bed board b. Tracheostomy set and oxygen c. Ampule of sodium bicarbonate d. Airway and nonrebreather mask

b. Tracheostomy set and oxygen A tracheostomy set and oxygen are necessary if the client experiences an acute respiratory obstruction as a result of postoperative edema, nerve damage, or tetany. A cardiac arrest is not an expected response after thyroid surgery. Acidosis requiring sodium bicarbonate and cardiac arrest are not expected responses after a thyroidectomy. If the airway is obstructed by postoperative edema, the use of a mechanical airway will be ineffective because it will not reach beyond the point of the obstruction. A nonrebreather mask is designed to deliver high concentrations of oxygen. In the event of an airway obstruction, the client's need is to circumvent the obstruction, not deliver high concentrations of oxygen.

Which model of ethics considers broad social issues and involves accountability to the overall institution? a. Autonomy model b. Paternalistic model c. Social justice model d. Patient-benefit model

c. Social justice model *The social justice model considers broad social issues and is accountable to the whole institution.* An ethics committee follows the autonomy model to facilitate decision making for a competent client. The paternalistic model is a type of decision-making style in which the nurse manager decides what to do. The patient-benefit model is accountable in substituted judgment (asking the client caregivers what the client requires in this type of situation).

Which statement does the nurse recognize as true according to chaos theory? a. Health-care organizations must be self-organizing. b. Health-care organizations must accept that change is avoidable. c. Successful managers are those who are intolerant to ambiguity. d. Successful nurse leaders are those who committed to short-term learning.

a. Health-care organizations must be self-organizing. *According to the proponents of chaos theory, organizations must be self-organizing and adapt readily to change in order to survive.* Health-care organizations accept that change is unavoidable and unrelenting. Using creativity and flexibility, successful managers will be those who can tolerate ambiguity, take risks and experiment with new ideas. Successful nurse leaders will be those individuals who are committed to lifelong learning and problem solving.

What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client? a. Monitoring clinical manifestations b. Collecting the data to be used in the assessment of the IV site c. Administering IV fluids and medications d. Evaluating the client for clinical manifestations

a. Monitoring clinical manifestations In IV therapy the role of the registered nurse is to collect the data that can be used in the assessment of the IV site. *Monitoring clinical manifestation is performed by the unlicensed assistive professional and report to the RN.* Administering IV fluids and medications is done by a registered nurse or LPN. Evaluating the client for clinical manifestations is performed by the registered nurse.

59. What would the nurse tell the parents is the acceptable range of heart beats per minute for a preschooler? a. 60-100 b. 80-110 c. 75-100 d. 90-140

b. 80-110 The acceptable range for a heart rate in preschoolers is 80 to 110 beats per minute. Adults have a range of 60 to 100 beats per minute. In school-aged children, the heart rate is from 75 to 100 beats per minute. The acceptable range of heart beats per minute in a toddler is 90 to 140 beats per minute.

Which statement is true regarding the satisficing decision model? a. It involves shared decision-making. b. A decision is made by analyzing pros and cons associated with each option. c. It allows for a quick decision, which is important when lack of time is an issue. d. It is more appropriate when conflict is likely to occur or when the problem is unstructured.

c. It allows for a quick decision, which is important when lack of time is an issue. *The satisficing decision model allows for quick decisions and is best to use when lack of time is an issue.* With shared decision-making, decisions are made through an interactive, deliberate process. In the optimizing decision style, decisions are made by analyzing pros and cons associated with each option. Autocratic decision-making is more appropriate when conflict is likely to occur or when the problem is unstructured

The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations? a. Nursing aide b. Certified technician c. Patient care associate d. Licensed practical nurse

d. Licensed practical nurse *Tetanus vaccination is administered through the intramuscular route. The licensed practical nurse can administer oral, topical, and intramuscular medications, except for intravenous. *The nursing aide, certified technician, and patient care associate are unlicensed assistive personnel whose scope of practice is limited for administering medications.

Which description by the nurse is a correct explanation of delegation? a. The transfer of responsibility for the performance of an activity b. The person's responsibility and accountability for individual actions or omissions c. The active process of directing, guiding, and influencing the outcome of an individual d. The transfer of both the accountability and responsibility from one person to another

a. The transfer of responsibility for the performance of an activity *Delegation is the transfer of responsibility for the performance of an activity.* Personal liability defines each person's responsibility and accountability for individual actions or omissions. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual. Assignment is the transfer of both the accountability and the responsibility from one person to another.

The nurse is entering a client's data in the electronic health record. What action should the nurse take to minimize ambiguity and confusion? a. Use consistent, codified terminology. b. Record the data in the client's presence. c. Enter the data in the client's native language. d. Upload scanned copies of the client's records.

a. Use consistent, codified terminology. An electronic health record is a client's official digital health record and is shared among multiple facilities and agencies. Therefore the nurse must use consistent, codified terminology to eliminate ambiguity and confusion. Recording the data in the presence of the client will not help another health care professional understand the data. Healthcare providers review electronic health record for continuing a client's treatment. Therefore the nurse should enter client data by using a clear codified scheme, not in the client's native language. The nurse should not upload scanned copies of client records because others may not understand the nurse's handwriting and may get confused.

The registered nurse considers the qualification of the unlicensed nursing personnel (UNP) before delegating a task. Which right of delegation is followed by the nurse? a. Task b. Person c. Direction d. Supervision

b. Person *The knowledge and experience to perform the specific task safely by the delegatee is assessed by the qualification of the delegatee, which determines whether he or she is the right person.* The right task involves assessing whether the task is legally appropriate to delegate or whether it is appropriate under institutional policies. The right direction involves the delegator providing clear and concise directions to perform the task. The right supervision is determined by whether the delegator is able to monitor and evaluate the client appropriately.

A nurse believes that a client who is being discharged after a physical attack by an unknown assailant will benefit from further care to help resolve residual feelings. For what type of therapy should the nurse refer the client? a. Psychotherapy that emphasizes desensitization b. Short-term therapy emphasizing crisis intervention c. Long-term therapy with a psychoanalytical emphasis d. Group therapy with a behavior modification component

b. Short-term therapy emphasizing crisis intervention Crisis intervention helps the client put the event in perspective and resolve feelings so the individual can resume life within a short time. Desensitization is effective if the victim develops phobias as a result of the physical attack. Unless there are complicating factors, long-term therapy is not indicated. The client's behavior did not precipitate the attack.

A nurse is on the crisis hotline with a client and has assessed identifying data. The client says, "Don't try to help me anymore. This is it. I've had enough and I have a gun in front of me now." Without another word, the client disconnects the call. What is the nurse's best course of action? a. Call the local clergyman and request an immediate visit. b. Call the client back and try to persuade a change of mind. c. Call the emergency hotline and inform the responder of the situation. d. Call the client's neighbors and ask them to go to the house immediately.

c. Call the emergency hotline and inform the responder of the situation. This is a serious situation that requires immediate intervention. The emergency hotline may be called to distract the client until help arrives. A clergyman may not be available or capable of helping the client. Asking a neighbor to go to the house is unsafe because the client may be dangerous to self and others.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? a. Abdominal girth decrease b. Mucous membranes becoming drier c. Heart rate increases from 80 to 135 d. Blood pressure rises from 130/70 to 190/80

c. Heart rate increases from 80 to 135 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

8. Which professionals in a healthcare organization can be delegators? a. Assistants b. Technicians c. Registered nurses d. Client care associates

c. Registered nurses *Registered nurses are professionals in a healthcare organization who can be delegators. The registered nurses allocate a portion of work related to client care to other individuals.* Assistants, technicians, and client care associates in a healthcare organization can be delegatees.

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? a. Assault is a threat to do bodily harm to another person. b. Assault is a legal wrong committed by one person against the property of another. c. Assault is a legal wrong committed against the public that is punishable by federal law. d. Assault is the application of force to another person without lawful justification.

a. Assault is a threat to do bodily harm to another person. Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by federal law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery.

An adolescent arrives at the clinic reporting buzzing in the ears. What assessment data are essential for the nurse to obtain? a. Music preferences b. Childhood ear infections c. Recent emotional trauma d. Familial history of deafness

a. Music preferences Tinnitus in adolescents is usually related to a preference for loud music, especially when headphones are used. Long-resolved ear infections usually have no sequelae, including buzzing in the ears. Tinnitus is a concrete occurrence; it is doubtful that it will emerge in the presence of emotional trauma. Familial deafness is not related to the recent development of tinnitus in an adolescent.

A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? a. Stimulation of the liver to produce an excess quantity of bile pigments b. Inability of the liver to remove normal amounts of bilirubin from the blood c. Increased destruction of red blood cells during the acute phase of the disease d. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding

b. Inability of the liver to remove normal amounts of bilirubin from the blood Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. With hepatitis, the liver does not secrete excess bile. Destruction of red blood cells does not increase in hepatitis. Decreased prothrombin levels cause spontaneous bleeding, not jaundice.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? a. Irritability, polydipsia, and polyuria b. Polyuria, polydipsia, and polyphagia c. Nocturia, weight loss, and polydipsia d. Polyphagia, polyuria, and diaphoresis

b. Polyuria, polydipsia, and polyphagia Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

Who would the nurse explain would go through the initiative versus guilt stage of Erikson's theory? a. Toddlers b. Preschoolers c. Old aged people d. Middle aged people

b. Preschoolers Preschoolers between the ages of 3 to 6 years of age are in the initiative versus guilt stage. During this stage, children like to pretend and play new roles. Toddlers will go through the autonomy versus guilt stage. By this stage, a growing child is more accomplished in some basic self-care activities, including walking, feeding, and toileting. The integrity versus despair stage of Erikson's theory relates to the elderly. Middle-aged people go through the generativity versus self-absorption and stagnation stage. Here, adults start focusing on future generations.

A client asks the nurse, "Because I'm so comfortable talking with you, can we go out for coffee and a movie after I get discharged?" To maintain the boundaries of a therapeutic relationship, how will the nurse respond? a. "I'm flattered, but that would be professionally unethical." b. "You feel connected to me now; that will change once you are discharged." c. "The attention I've been giving you is directed toward getting you better; it isn't social." d. "A social life is important, so as your nurse let's talk about how you can form friendships."

d. "A social life is important, so as your nurse let's talk about how you can form friendships." Clients often become socially interested in the nursing staff. When this occurs the nurse should remind the client of the nursing role and take the opportunity to discuss the need for friendships and how to achieve them best. Stating "I'm flattered, but that would be professionally unethical"; "You feel connected to me now; that will change once you are discharged"; and "The attention I've been giving you is directed toward getting you better; it isn't social," although not untrue or inappropriate, do not best address the nursing responsibility in this therapeutic role.

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel

a. Registered nurse *The registered nurse is accountable for the initial assessment and ongoing evaluation of the client.* A licensed practical nurse is not accountable for initial assessment and ongoing evaluation of the client. The primary health care provider is accountable for diagnosing the problem and reviewing the client responses. An unlicensed nursing personnel performs the tasks delegated by the registered nurse or other delegators.

A nurse gives a teenager discharge instructions regarding cast care. The nurse concludes that the instructions have been understood when the teenager makes what statement? a. "If I get itchy around the cast, I'll rub the itchy area gently." b. "If I get itchy around the cast, I'll pat the area with an alcohol swab." c. "If I get itchy around the cast, I'll ask my doctor for a prednisone prescription." d. "If I get itchy around the cast, I'll sprinkle a layer of powder around the itchy spots."

a. "If I get itchy around the cast, I'll rub the itchy area gently." Gentle rubbing may soothe the skin; stimulation of sensory neurons by rubbing may decrease the itching sensation. Alcohol is a drying agent and should not be used. Steroids such as prednisone are not routinely given for itching caused by a cast. Powder may become caked, slip under the cast, and cause additional discomfort. Also, powder, which is a respiratory irritant, may be inhaled.

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? a. 68 mg/dL (3.8 mmol/L) b. 78 mg/dL (4.3 mmol/L) c. 88 mg/dL (4.9 mmol/L) d. 98 mg/dL (5.4 mmol/L)

a. 68 mg/dL (3.8 mmol/L) Normal blood glucose level for an adult is 72-108 mg/dL (4-6 mmol/L). Clients who have blood glucose levels below 72 mg/dL (4 mmol/L) may experience hypoglycemia; 78 mg/dL (4.3 mmol/L), 88 mg/dL (4.9 mmol/L), and 98 mg/dL (5.4 mmol/L) are normal blood glucose levels.

Which activity indicates improper follow-through on the part of the delegatee? a. Failure to report results b. Failure of effective communication c. Performing a task in the absence of a delegator d. Failure in following guidelines provided by a delegator

a. Failure to report results *Failure to report the results and findings to the delegator indicates improper follow-through on the part of delegatee. Failure of effective communication is not considered improper follow-through on the part of the delegatee. Effective communication is required in leadership. The delegatee may perform the task in the absence of the delegator because the delegator may work elsewhere after delegating the task to the delegatee. It is the responsibility of the delegator to check if the delegatee is following proper guidelines; therefore it may not be considered improper follow-through.*

A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? a. Use normal saline to irrigate the tube. b. Employ sterile technique when irrigating the tube. c. Withdraw the tube quickly when decompression is terminated. d. Allow the client to have small sips of ice water unless nauseated.

a. Use normal saline to irrigate the tube. Patency of the tube should be maintained to ensure continued suction. Use of normal saline minimizes fluid and electrolyte disturbances during irrigation. The stomach is not considered a sterile body cavity, so medical asepsis is indicated. Care must be taken to avoid traumatizing the mucosa. Ice chips and water represent fluid intake, which must be approved by the healthcare provider; being hypotonic in nature, such intake may lower the level of serum electrolytes.

A nurse administrator needs to assess the quality of health care delivered in the hospital. What is the most important prerequisite for measuring health care quality? a. To implement the root cause analysis tool b. To review all the incident reports documented c. To collect all the medical records of the hospital d. To prepare nurse performance evaluation forms

c. To collect all the medical records of the hospital The most important prerequisite for assessing the quality of health care delivery system is to collect the medical records of the patients admitted and discharged from the hospital. The process of care provided to the patients and the outcomes of care are the most important determiners of health care quality. The nurse performance evaluation forms should be prepared to assess the clinical skills and knowledge of the nurses working in the health care system. The incident reports document the adverse events that have occurred in a hospital due to medical errors. These alone do not predict the health care quality provided in a health care system. The root cause analysis tool only helps find the cause of sentinel events that have occurred in the hospital.

Assessment data are collected on four different clients being assessed for safety risks to themselves and others. Which client does the nurse identify as being at the greatest risk for violent behavior? a. *Client 1* History of being physically and sexually abused by family member from ages 4 to 12 years; exhibits stress through hyperactivity b. *Client 2* History of violent behavior when under the influence of alcohol; has been abusing alcohol for 10 yrs c. *Client 3* Currently oriented but displays impaired memory; frequently unable to recognize familiar caregivers d. *Client 4* Currently paranoid; suspicious of "FBI agents"

A history of physical or sexual abuse coupled with the tendency to demonstrate hyperactive psychomotor agitation puts this client at the highest risk for violence among the assessed clients. A history of violence when inebriated is a low risk factor, regardless of how long the client has been abusing alcohol. Memory impairment that includes poor recognition of familiar individuals is a moderate risk for violence. Paranoid tendencies directed toward vague individuals or situation pose a moderate risk for violence.

Which process involves transferring responsibility to multiple players, usually with varying degrees of education and experience, while retaining the ultimate accountability for providing the client care? a. Leadership b. Delegation c. Supervision d. Assignment

B. Delegation *Delegation is a process of sharing the responsibility of client care. It involves the transfer of responsibility for the performance of an activity from one individual to another, with the delegator retaining accountability for the outcome.* Leadership is the use of individual traits and abilities in relationship with others, the ability to interpret the context where a situation is emerging, and entering that situation in the absence of a script or defined plan that could have been projected. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity. Assignment is the transfer of both the accountability and the responsibility from one person to another.

Who functions as a liaison between team leaders and other healthcare providers? a. Charge nurse b. Registered nurse c. Nursing manager d. Chief nursing officer

a. Charge nurse *The charge nurse functions as a liaison between team leaders and other healthcare providers.* Registered nurses function as accountable and responsible people for delegated tasks. Nursing managers are responsible for more than one unit and have other managerial responsibilities. Chief nursing officers are accountable for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation.

When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. a. Slowing of the heart rate b. Diminished carotid pulses c. Bleeding from the oral cavity d. Absence of deep tendon reflexes e. Increased pulse pressure f. Altered level of consciousness

a. Slowing of the heart rate c. Bleeding from the oral cavity e. Increased pulse pressure f. Altered level of consciousness Increased intracranial pressure from bleeding into and swelling of tissues within the cranium results in a slowing of the heart rate, an increased pulse pressure (due to increasing systolic blood pressure with a sustained diastolic blood pressure), and an altered level of consciousness. Carotid circulation is not altered. Bleeding from the oral cavity can occur in this situation and should be assessed for the presence of cerebral spinal fluid (CSF). Spinal reflexes generally remain intact.

Which questions should the delegator assess to determine the right task? Select all that apply. a. "Is the task legally appropriate to delegate?" b. "Is the environment conducive to completing the task safely?" c. "Does the delegator provide clear and concise directions for the task?" d. "Is the task appropriate to delegate based on institutional policies and procedures?" e. "Does the delegatee have the knowledge and experience to perform the specific task safely?"

a. "Is the task legally appropriate to delegate?" d. "Is the task appropriate to delegate based on institutional policies and procedures?" *The delegator has to determine right task by assessing whether the task is legally appropriate to delegate. The delegator must also check that the task is appropriate to delegate based on institutional policies and procedures.* The right circumstance can be assessed by asking, "Is the environment conducive to completing the task safely?" The right direction and communication is assessed by asking, "Does the delegator provide clear and concise directions for the task?" The right person eligible to accomplish the task is assessed by asking, "Does the delegatee have the knowledge and experience to perform the specific task safely?"

A 17-year-old adolescent with a history of asthma is brought to the emergency department in respiratory distress. A nurse immediately places the client in a bed with the head of the bed elevated and administers oxygen with a facemask. The primary healthcare provider performs a physical assessment and admits the adolescent to the pediatric unit. What is the priority nursing intervention in regard to the primary healthcare provider's prescriptions? *Physical Assessment* Dyspnea flaring of nares productive cough; sputum is frothy, clea and gelatinous *Primary healthcare provider's orders* bed rest complete blood count SMA: 12 Albuterol 2.5 mg via neblizer, one dose Chest physiotherapy b.i.d. incentive spirometer oxygen via mask at 8L Referral to allergist *Vital Signs* temp: 98.8 F Pulse: 108 bpm Resp: 30 breath/min BP" 130/86 mmHg a. Administering the nebulizer treatment to facilitate breathing b. Obtaining a blood specimen to send to the laboratory for tests c. Notifying the respiratory therapist to perform chest physiotherapy d. Sending a requisition to central supply for an incentive spirometer

a. Administering the nebulizer treatment to facilitate breathing Albuterol relaxes smooth muscles in the respiratory tract, resulting in bronchodilation. The priority is the facilitation of respiration. Administering albuterol follows the ABCs of emergency care: airway, breathing, and circulation. Obtaining a blood specimen to send to the laboratory for tests is not the priority. The results will not influence the priority intervention. Asking the respiratory therapist to perform chest physiotherapy is not the priority. Chest physiotherapy is performed after the respiratory airways are opened. In many facilities chest physiotherapy is the responsibility of the nurse, not a respiratory therapist. The use of an incentive spirometer can be taught after the acute episode of respiratory distress. It will take time to obtain the device and teach the adolescent.

Which actions can an effective mentor expect from an aspiring leader? Select all that apply. a. Being loyal b. Assisting with projects c. Sharing personal problems d. Maintaining confidentiality e. Giving a fee in terms of rewards

a. Being loyal b. Assisting with projects d. Maintaining confidentiality *The mentor has a right to expect loyalty, respect, assistance with projects, and confidentiality from the aspiring leader. An effective mentor does not expect a fee or rewards and gives guidance to balance the professional and personal work of an aspiring leader.*

Which information would the nurse include regarding appliance care and maintenance, when teaching a client with a new colostomy? Select all that apply. a. Change the ostomy pouch on a routine basis. b. Replace the ostomy wafer weekly or sooner as needed. c. Remove the ostomy pouch when showering. d. Empty the ostomy pouch when three-quarters full of stool or gas. e. Empty the ostomy pouch before exercise and at bedtime.

a. Change the ostomy pouch on a routine basis. b. Replace the ostomy wafer weekly or sooner as needed. e. Empty the ostomy pouch before exercise and at bedtime. Tips for limiting stool leakage are important for the client with an ostomy, in regards to comfort and dignity. Changing the ostomy pouch on a routine basis will decrease the risk of leakage. Twice weekly changes are considered typical. It is also recommended that the skin barrier (wafer) be changed at least once weekly and as needed if sooner, in order to protect the integrity of the skin beneath and around it. Emptying the pouch before activities and before bedtime will also help prevent leakage and overfill. It is recommended to shower or bathe with the pouch on, not off. This helps to maintain the integrity of the wafer and to prevent any stool from leaking onto the skin or into the shower while bathing. Clients should be instructed to have a new pouch at the ready, to be exchanged with the old pouch, after showering. Waiting to empty the pouch until it is more than one-half full increases the likelihood of leakage. Emptying the pouch sooner will prevent overfill and leakage.

The nurse is reviewing the case history and disease prognosis of various clients. Which would the nurse consider as a near-miss event? a. *Client A* Condition:Lower limb surgery--Event Patient develops respiratory arrest after spinal anesthesia but is intubated in a timely manner b. *Client B* Condition: Stroke--Event: Patient develops grade IV pressure sores c. *Client C* Condition: DVT--Event Patient was given limb exercises, and the patient later developed pulmonary embolism d. *Client D* Condition: Fever--Event: Patient developed febrile seizure

a. Client A A near-miss is an error that could have caused harm to a client but did not due to some intervention that saved the client from the effect of the error. Client A was rescued from respiratory arrest due to timely intubation. This is an example of a near-miss event. Client B who had stroke had developed pressure sores resulting from poor quality care. This is an example of an adverse event. Client C who had deep vein thrombosis had developed pulmonary embolism, which is a life-threatening complication. This is a type of a sentinel event. Client D who had fever had developed febrile seizures, which may have resulted due to inappropriate management. This is also a type of adverse event.

Which beliefs may be associated with a registered nurse's failure to delegate tasks? Select all that apply. a. Delegation is too time consuming. b. More energy is required to delegate others. c. The registered nurse will not receive credit for total client care. d. Delegation minimizes the contribution of the delegator for client care. e. Delegation requires complete transfer of accountability for final client care.

a. Delegation is too time consuming. b. More energy is required to delegate others. c. The registered nurse will not receive credit for total client care. Failure to delegate to others is an issue of concern. Some registered nurses believe that delegation of work is very time consuming and requires more energy to explain and supervise the tasks allotted to the delegatee. Others want the credit and recognition for total client care. Successful delegation maximizes the delegator's contribution to the client care. Delegation does not involve the transfer of accountability for final client care.

What are the three strategies that the nurse can perform while assisting other nurses in making delegation decisions? Select all that apply. a. Doing b. Telling c. Asking d. Offering e. Participating

a. Doing c. Asking d. Offering *The nurse can assist other registered nurses with delegation decisions by using three strategies: asking, offering, and doing.* Telling and participating are the strategies used by the nurse to communicate with the delegatee.

Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include? a. Encouraging daily physical exercise b. Performing yearly physical examinations c. Providing hypertension screening programs d. Teaching a person with diabetes how to prevent complications

a. Encouraging daily physical exercise Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.

Which skills would be essential for an effective nurse manager to develop and improve collaboration with others? Select all that apply. a. Flexibility b. Reacting hastily c. Showing frustration d. Ability to listen to others e. Ability to share information and ideas

a. Flexibility d. Ability to listen to others e. Ability to share information and ideas *In order to collaborate effectively, the nurse should be flexible, must be willing to listen to others, and must share information and ideas with others.* The nurse manager should plan a thoughtful response, consider others' perspective first, and not react hastily. The nurse manager should not share his or her own anger or frustration with other staff.

What should be the nurse's focus when caring for a client after abdominal surgery? a. Identifying signs of bleeding b. Preventing pressure on the suture site c. Encouraging use of an incentive spirometer d. Detecting clinical manifestations of inflammation

a. Identifying signs of bleeding Bleeding and hemorrhage are the most serious concerns. Bleeding disorders are common when bile does not flow through the intestine. Phytonadione, a fat-soluble vitamin synthesized in the small intestine, requires bile salts for its absorption; phytonadione is used by the liver to synthesize prothrombin necessary for clotting. Preventing pressure on the suture site, encouraging use of an incentive spirometer, and detecting clinical manifestations of inflammation are not as serious concerns.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? a. Incontinence and inability to move independently b. Periodic diaphoresis and occasional sliding down in bed c. Reaction to just painful stimuli and receiving tube feedings d. Adequate nutritional intake and spending extensive time in a wheelchair

a. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

A nurse is discussing the regaining of bowel control with a client who recently had surgery for a colostomy in the descending colon. What is most important to emphasize in this teaching? a. Irrigation routine b. Management of fluid intake c. Progressive exercise program d. Maintenance of a low-residue diet

a. Irrigation routine Colostomy irrigations done daily at the same time help to establish a regular pattern of bowel evacuation. Although adequate fluid intake is important to prevent hard stools, it will not help the client regain bowel control. Progressive exercise has no relationship to bowel control for a client with a distal colostomy; however, exercise does help prevent constipation. A soft, low-residue diet is not necessary.

A client is admitted to the hospital with a possible diagnosis of Addison disease. What is an important nursing responsibility during a 24-hour urine collection for this client? a. Keeping the client quiet and reducing stress b. Assessing the client for signs and symptoms of edema c. Monitoring the client for an elevation in blood pressure d. Restricting the client's fluid intake during the day of the test

a. Keeping the client quiet and reducing stress Stress and activity increase the secretion of adrenocorticotropic hormone (ACTH) and adrenocortical hormones, elevating the urine values for the by-products of these hormones, thus invalidating the test results. Clients with Addison disease chronically are dehydrated and do not have edema. Because of fluid deficits, the client will be hypovolemic, and the blood pressure will be decreased. Adequate fluid intake is necessary for urine production; Addison disease involves salt wasting and dehydration, which necessitates an increased fluid intake, not a restriction of fluid intake.

The count of hydrocodone is incorrect. After several minutes of searching the medication cart and medication records, no explanation is found. Who should the primary nurse notify about the discrepancy? a. Nursing unit manager b. Hospital administrator c. Quality control manager d. Healthcare provider prescribing the medication

a. Nursing unit manager *Controlled substance issues for a particular nursing unit are the responsibility of that unit's nurse manager. Responsibility flows directly from the staff of a nursing unit to the nurse manager; the nurse manager reports to a nurse administrator.* There is no direct flow of accountability from the primary nurse to the quality control manager. Healthcare providers are responsible for medical management issues, not issues associated with management of a nursing unit.

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin. Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation? Select all that apply. a. Presence of blood in urine (hematuria). b. Bruising noted at various stages of healing. c. Delayed clotting from minor cuts and scrapes. d. Bleeding from gums when brushing teeth. e. Vomiting coffee-ground emesis.

a. Presence of blood in urine (hematuria). e. Vomiting coffee-ground emesis. Warfarin causes an increase in the prothrombin time and international normalized ratio (INR) level, leading to an increased risk for bleeding. Any abnormal or prolonged bleeding must be reported, because it may indicate an excessive level of the drug. Common side effects including bruising, delayed clotting and bleeding gums do not require immediate intervention. However, hematuria and hemoptysis are evidence of more serious bleeding and require immediate attention. Coffee-ground emesis is a sign of gastric bleeding. Even though the emesis is not bright red, it still requires immediate attention by a healthcare provider.

The registered nurse (RN) is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the unlicensed assistive personnel (UAP) to provide quality care to the client? Select all that apply. a. Recording vital signs b. Assisting the client with bathing c. Administering oral medications d. Preparing the care plan for the client e. Administering intravenous antibiotics

a. Recording vital signs b. Assisting the client with bathing *The tasks within the scope of unlicensed assistive personnel (UAP) include recording vital signs and providing basic hygiene, such as assisting the client with activities of daily life such as bathing.* Administering oral medications is under the scope of licensed practical nurse (LPN) or licensed vocational nurse (LVN), but not the UAP. Depending on the state, administering intravenous antibiotics can be performed by either the RN or an LPN/LVN. Preparing the care plan for the client should be performed by the registered nurse only.

A 13-year-old who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for further testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. Which is the best response by the nurse? a. Refer the mother to the psychiatrist. b. Explain to the mother the results of the tests. c. Suggest that the mother call the psychologist. d. Teach the mother about the tests that were administered.

a. Refer the mother to the psychiatrist. It is the responsibility of the psychiatrist, who is the primary healthcare provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered. It is important that this student get the testing and counseling needed since the future problems of bullies include a higher risk for conduct problems, hyperactivity, school dropout, unemployment, and participation in criminal behavior. Chronic bullies seem to continue their behaviors into adulthood, negatively influencing their ability to develop and maintain relationships

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel

a. Registered nurse The registered nurse is accountable for the initial assessment and ongoing evaluation of the client. A licensed practical nurse is not accountable for initial assessment and ongoing evaluation of the client. The primary health care provider is accountable for diagnosing the problem and reviewing the client responses. An unlicensed nursing personnel performs the tasks delegated by the registered nurse or other delegators.

Which healthcare professional would the nurse know is held accountable for the tasks performed by the patient care associate (PCA)? a. Registered nurse (RN) b. Licensed vocational nurse (LVN) c. Unlicensed assistive personnel (UAP) d. Unlicensed nursing practitioner (UNP)

a. Registered nurse (RN) *The delegator is held accountable for tasks performed by the delegatee. In this situation, the delegator is the RN; therefore, the RN is held accountable for the tasks performed by the PCAs.* The RN is also accountable for delegation to LVNs, UAPs, and UNPs as delegatees.

A client with a severe allergy has been administered a high dose of antihistamine. The nurse finds that the client is drowsy and dizzy. Which type of need would the nurse prioritize in the client according to Maslow's hierarchy of needs? a. Safety need b. Belonging need c. Self-esteem need d. Self-actualization need

a. Safety need *Clients suffering from the effects of a high dose of antihistamines have strong safety needs.* The belonging need is fulfilled when the client is provided love and compassion. Self-esteem needs are fulfilled by providing recognition. Self-actualization needs may not be the priority of the client in the current situation.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? a. Sodium and chloride levels b. Bicarbonate and sulfate levels c. Magnesium and protein levels d. Calcium and phosphate levels

a. Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? a. Start the time of the test after discarding the first voiding. b. Discard the last voiding in the 24-hour time period for the test. c. Insert a urinary retention catheter to promote the collection of urine. d. Strain the urine following each voiding before adding the urine to the container.

a. Start the time of the test after discarding the first voiding. The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse as a leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply. a. Surgery procedures b. Name of the surgeon c. Description of the risks d. Anesthetic drug used during pre-operation e. Name of the staff members who will be in the surgery

a. Surgery procedures b. Name of the surgeon c. Description of the risks *Informed consent must be done according to legal guidelines. It is an authorization by the client to perform a surgery or procedure on them. Therefore the detail about the procedure of the surgery must be provided. It also informs the client about the name of the person who is performing the procedure. A description of the possible risks of the procedure is conveyed through informed consent.* The name and type of anesthetic drug to be used may not be included in the informed consent. The name of the staff members involved in the surgery may not be a part of the informed consent.

Which belief of a nurse may have a negative effect on health services for minority clients? a. The mind, body, and spirit are distinct entities. b. The focus of an assessment should be on culture rather than race for children of multiracial, multicultural, and multiheritage marriages. c. Chinese clients may believe that disease is caused by fluctuations in opposing forces, the yin-yang energies. d. When taking a client history, the nurse should record the client's race according to how he or she self identifies.

a. The mind, body, and spirit are distinct entities. Eastern tradition considers body-mind-spirit as a single entity; if the nurse refuses to accept and respect that a client of a different culture may believe this, then the quality of care can be affected. Children of multiracial, multicultural, and multiheritage marriages fall into more than one category, so the nurse should focus on culture rather than race. For the Chinese, disease is caused by fluctuations in opposing forces—the yin-yang energies. The nurse should not make assumptions about a client's race based on his or her appearance; the nurse should record the client's race as he or she self-identifies.

The nurse manager working at a rehabilitation center for older adults notices an increase in the incidence of client falls. The nurse manager reprimands the nurses and staff responsible for the falls and places them on probation. Which statement best describes the nurse manger's leadership style? a. The nurse manager exhibits autocratic leadership. b. The nurse manager demonstrates shared leadership. c. The nurse manger exhibits good clinical leadership skills. d. The nurse manger demonstrates effective interprofessional leadership.

a. The nurse manager exhibits autocratic leadership. The nurse manager in this scenario exhibits autocratic leadership. In an autocratic leadership style, all decisions are solely made by the leader. Autocratic leaders are more concerned about the task and may use the threat of punishment to accomplish it. The nurse manager is not involved in direct patient care and so is not demonstrating clinical leadership. The nurse manger is not involving the staff in the decision-making process and thus is not demonstrating shared leadership. The nurse manger is not

The registered nurse is delegating to four unlicensed nursing personnel (UNP) who are performing various delegated client care activities. Which UNP needs more education and monitoring? a. UNP A--Client Diabetes--Activity: Measuring blood glucose levels immediately after a meal b. UNP B--Client: Hypothyroidism--Activity: Producing accurate account of the client's condition c. UNP C--Client: Hypertension--Activity: Documenting the blood pressure levels of the client d. UNP D--Client: Headache--Activity: Asking the client to sleep in dark room

a. UNP A--Client Diabetes--Activity: Measuring blood glucose levels immediately after a meal *The registered nurse has to carefully select the eligible staff to complete a given task in a productive manner. The registered nurse has to educate, guide, and monitor the unlicensed nurse (UNP) who measures the blood glucose levels immediately after meals. The food takes time to be digested and absorbed into the blood, therefore, the blood glucose levels should be checked an hour after a meal. The registered nurse should provide motivational feedback about the working performance to the respective UNP.* A registered nurse should be accountable for the delegated task; UNP B should be responsible for providing proper client care. UNP C should document the blood pressure and other information related to client care for future accountability. UNP D may provide simple, straight forward information to the client.

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply? a. "What makes you think you have cancer?" b. "I don't know if you do; let's talk about it." c. "Why don't you discuss this with your primary healthcare provider?" d. "You needn't worry now; we won't know the answer for a few days."

b. "I don't know if you do; let's talk about it." The nurse has demonstrated recognition of the verbalized concern and a willingness to listen. The client did not state cancer as the diagnosis; this response puts the client on the defensive. Avoiding the question indicates that the nurse is unwilling to listen. Saying the client shouldn't worry cuts off communication and denies feelings.

A nurse manager is selecting direct care nurses for a client-care project. The manager asks a direct care nurse about treatment priorities. Which answer provided by the direct care nurse would be appropriate? a. "I will give preference to the problems that are encountered first." b. "I will give preference to the problems that have the greatest urgency." c. "I will give preference to the problems that appear to be easiest to resolve." d. "I will give preference to the problems that take the shortest amount of time to resolve."

b. "I will give preference to the problems that have the greatest urgency." *The preference for treatment should be always given to problems that have the greatest urgency such as life-threatening conditions.* Secondary preference should be given to problems that are encountered first, problems that appear to be easiest to resolve, and problems that take the shortest amount of time to resolve.

Which statement made by a diabetic client shows that dietary teaching by the nurse was effective? a. "My diet should be rigidly controlled to avoid emergencies." b. "My diet can be planned around a wide variety of commonly used foods." c. "My diet is based on nutritional requirements that are the same for all people." d. "My diet must not include eating any combination dishes and processed foods."

b. "My diet can be planned around a wide variety of commonly used foods." Each client should be given an individually devised diet consisting of commonly used foods from the American Diabetic Association (Canadian Diabetes Association) diet; family members should be included in the diet teaching. Rigid diets are difficult to follow; appropriate substitutions are permitted. Nutritional requirements are different for each individual and depend on many factors, such as activity level, degree of compliance, and physical status. Combination dishes and processed foods can be eaten when accounted for in the dietary regimen.

Before a treatment requiring informed consent can be performed, what information must the client be given? Select all that apply. a. The cost of the treatment b. Alternative treatment options c. The risks and benefits of the treatment d. The risks involved in refusing the treatment e. The nature of the problem requiring the treatment

b. Alternative treatment options c. The risks and benefits of the treatment d. The risks involved in refusing the treatment e. The nature of the problem requiring the treatment For consent to be legal it must be informed. The information provided to the client includes the nature of the problem or condition, the nature and purpose of the proposed treatment, and the risks and benefits of the treatment. Alternative treatment options, the probability that the proposed treatment will be successful, and the risks involved in not consenting to the treatment must also be provided. Cost of the treatment is not considered relevant to informed consent.

A nurse manager is informed that a community disaster drill will take place. The disaster scenario will include a bombing in a shopping mall with hundreds of casualties. What location should the nurse consider for triage of casualties when planning for this exercise? a. In the hospital parking lot b. At the scene of the disaster c. In the emergency department d. At the closest school gymnasium

b. At the scene of the disaster Triage is initiated at the scene. After the scene is determined to be safe for the healthcare team to approach, providers at a mass casualty incident (MCI) must analyze the number and severity of clients. Regardless of the system used, the primary goal is to quickly sort the clients into transport categories and identify each of them with triage tags, colored tape or other means of priority. Mass casualty events have triage at the scene to prevent overwhelming the hospital with casualties, while at the same time preventing the hospital from becoming a secondary target of additional attacks. The hospital parking lot is too close to the hospital to provide safety from additional attacks. Performing triage in the emergency department will quickly overwhelm the department and will interfere with provision of care to clients who will benefit from interventions. The closest school gymnasium may be too far from the scene of the disaster and may become a target of secondary attack.

How should nurses provide effective nursing care to clients from different cultural backgrounds? a. By advising clients that some cultural practices may be harmful to health b. By providing care that fits the clients' cultural beliefs c. By strictly adhering to organization policies regarding nursing care d. By ignoring the cultural aspect and focusing on the medical aspect of care

b. By providing care that fits the clients' cultural beliefs *When providing care to clients from different cultural backgrounds, nurses should be careful to provide care that fits the client's cultural beliefs. It helps provide effective nursing care to the satisfaction of the client.* Advising clients against their cultural practices may offend them and should be avoided. Organization policies should be made flexible to incorporate cultural aspects of care. Ignoring the cultural aspect of client care may result in ineffective nursing care.

How does a nurse leader effectively implement change in an organization? a. By avoiding using managerial skills b. By using personal and professional skills c. By avoiding giving timely feedback to team members d. By removing the ineffective team members from the group

b. By using personal and professional skills *A nurse leader should use both personal and professional skills to ensure effective implementation of a change in an organization.* A nurse leader should also use managerial skills, not avoid them, to ensure effective implementation of a change in an organization. A nurse leader should give regular and timely feedback to the team members to implement change effectively. A nurse leader should motivate the team members to work effectively rather than removing them from the team.

Who would the registered nurse state is accountable for establishing systems to communicate competency requirements related to delegation? a. Registered nurse (RN) b. Chief nursing officer (CNO) c. Licensed practical nurse (LPN) d. Unlicensed assistive personnel (UAP)

b. Chief nursing officer (CNO) *CNOs are accountable for establishing systems to communicate competency related to delegation.* The registered nurse delegates the task to LPN and UAP. In delegation, the RN implements in clinical practice to improve the safety and quality of client care. LPNs provide direct care to the client. UAP provide direct care to the client under the supervision of the registered nurse who retains accountability for client care outcomes.

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? a. Client A--94.2F b. Client B--85.3F c. Client C--89.4F d. Client D--91.5F

b. Client B--85.3F Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.

The nurse leader noticed that the staff nurse recently promoted to the surgical unit is lacking confidence at work and is worried about a pending review by the nursing director. Which source of power is applicable in this situation? a. Reward power b. Coercive power c. Referent power d. Connection power

b. Coercive power *Coercive power stems from a real or perceived fear of another person.* Reward power is perceived as being able to provide rewards or favors. Association with a powerful person grants referent power. Association with people who are powerful or who have links to powerful people gains connection power.

Which theory related to leadership is a nontraditional theory that has emerged from the physical and social sciences? a. Expectancy theory b. Complexity theory c. Motivational theory d. Management theory

b. Complexity theory *Complexity theory is a nontraditional theory emerging from the work of the physical sciences and, more recently, social sciences.* Expectancy theory posits that motivational behavior is increased by rewarding good and innovative performance; it is not rooted in the physical sciences. Motivational and management theories are traditional theories of leadership.

What are the qualities of an effective leader? Select all that apply. a. Born with the right stuff b. Elicit a vision from people c. Bring out the best in people d. Engender discipline and obedience e. Inspire people to bring the vision into reality

b. Elicit a vision from people c. Bring out the best in people e. Inspire people to bring the vision into *Leadership is the ability to elicit a vision from people and to inspire and empower those people to do what it takes to bring the vision into reality. A leadership quality is to bring out the best in people.* Leaders are not born with the right stuff; rather they develop these qualities gradually over time when they perform with the right kind of attitude and determination. Leaders must possess the ability to inspire the commitment of followers and allow them to achieve goals autonomously rather than simply engendering discipline and obedience.

Which theory states that the leadership traits in an individual are born and not made? a. Style theory b. Great Man theory c. Two-factor theory d. Situational-contingency theory

b. Great Man theory *The trait theory is sometimes referred as the Great Man theory. According to this theory, the leadership traits such as a certain set of physical and emotional characteristics are innate and cannot be learned.* Style theory focuses on what leaders do, but not on the leadership qualities. Two-factor theory focuses on motivation and job satisfaction based on hygiene factors and motivational factors. Situational-contingency theory focuses on the challenge of a situation and encourages an adaptive leadership style particular to that situation.

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. What should the nurse do to promote psychologic adjustment and early function immediately after surgery? a. Allow the client to change the first dressing. b. Help the client adjust to the temporary prosthesis. c. Assign the client to a room with another adolescent. d. Have the client meet with a member of a cancer survivor organization.

b. Help the client adjust to the temporary prosthesis. A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.

A client with a history of multiple chronic illnesses comes to the emergency department (ED) reporting a slight progressive weight loss over the last month as well as frequent urination and feeling lethargic, hungry, and thirsty all the time. The client's vital signs are blood pressure (BP) 118/78 mm Hg, oral temperature 99.6 °F (37.6 °C), and regular pulse of 72 beats per minute with irregular respirations of 22 breaths per minute. What condition does the nurse suspect that this client is experiencing? *Medications* Furosemide: 40 mg PO once per day Glyburide: 5mg PO twice per day Warfarin soidum: 10mg once per day Fluticaone: 250 mcg and salmeterol: 50mcg 1 puff twice per day *Medical History* Asthma diagnosed 25 years ago Non-insulin dependent diabetes melitus diagnosed 15 yrs ago Atrial fibrillation & ablation of atrioventricular (AV) node 10 yrs ago Pacemaker insertion 10 yrs ago, set at 70 BPM *Lab Results* INR: 2.5 Fasting blood glucose: 180 mg/dL a. Hypervolemia b. Hyperglycemia c. Infectious process d. Respiratory distress

b. Hyperglycemia The client is reporting a slight progressive weight loss over the last month and feeling lethargic, hungry, and thirsty all the time. These adaptations are related to hyperglycemia. The client's blood pressure is within the expected range for an adult. The average blood pressure of a healthy adult is 120/80 mm Hg. The blood pressure will be decreased and heart rate increased if a client is experiencing hypervolemia. The client's temperature is within the expected range for an adult (96.8 to 100.4 °F) (36 to 38 °C). The temperature will be increased when a client is experiencing an infectious process. Although the respiratory rate of 22 breaths per minute is slightly more than the expected respiratory rate for a healthy adult (15 to 20 breaths per minute), the client is not exhibiting signs of respiratory distress (e.g., labored breathing, use of accessory muscles of respiration).

The nurse manager hears a conversation between a nurse and a client that is focused on the details of their impending divorces. What is the nurse manager's response? a. Waiting until the conversation ends and then telling the nurse that such topics must be discussed in strict privacy to ensure client confidentiality b. Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated c. Immediately explaining to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed d. Waiting until shift report and using that opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff

b. Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated The nurse-client relationship should always remain client focused. Discussing personal issues with the client, even in an attempt to share similar experiences, is nontherapeutic and should be discussed immediately by the nurse's supervisor. Although the ease with which this conversation was overheard does raise concerns about the nurse's understanding of the client's right to confidentiality and privacy, there is a greater issue that needs immediate attention and should be addressed immediately. The nurse's management of the nurse-client relationship should be discussed privately. It may not be necessary to change the assignment. Although it may be useful to reinforce information on privacy with the entire staff, the situation requires an immediate private discussion between the nurse and the nurse manager to satisfactorily address the problem for the individual nurse.

What are the characteristics of an adverse hospital event? Select all that apply. a. It may also result in death at times. b. It may cause minimal harm to the patient. c. It is caused by human or hospital system error. d. It is caused by severe variation in the standard of care. e. Its cause can be analyzed using the root cause analysis tool.

b. It may cause minimal harm to the patient. c. It is caused by human or hospital system error. An adverse hospital event is a medical error that may result in causing harm to the patient. However, the harm is not too severe or life-threatening to the patient. Adverse events are caused by human errors made by health care professionals or error in the hospital system. Sentinel events may result in death of the patient and are caused by severe variation in the standard of care. Sentinel events are analyzed using the root cause analysis tool. Adverse hospital event is analyzed using the failure mode effective analysis tool.

Which statement is true regarding leadership? a. Having the title of chief executive officer indicates a good leader. b. Leadership is an earned honor and an action-oriented responsibility. c. Playing an administrative role can automatically place the title of leader on an individual. d. Strengthening the mission of an organization purely depends on the leader himself or herself.

b. Leadership is an earned honor and an action-oriented responsibility. *Leadership is an earned honor, right, and privilege and an action-oriented responsibility that requires a time commitment.* Having a title such as chief executive officer or chief nursing officer does not guarantee that a person will be a good leader. Administrative or management roles do not automatically confer the title of leader on an individual. Strengthening the mission of organization depends on both a good leader and follower.

A nurse leader is caring for a client during their entire stay in the hospital. Which nursing model is this nurse following? a. Team nursing b. Primary nursing c. Functional nursing d. Case method nursing

b. Primary nursing *The primary nursing model brings the nurses back to direct client care. This means that the primary nurse provides coordinated, comprehensive, and continuous care to the client and the family.* Team nursing involves different personnel such as registered nurses and licensed practical nurses assigned to a single client and responsible for different tasks. The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs certain tasks for a large group of patients. In the case method model of nursing, nurses do not provide continuous care to the client and different nurses are assigned to a single client.

An 8-year-old child with a terminal illness is demanding of the staff. The child asks for many privileges that other children on the unit do not have. The staff members know that the child does not have long to live. The nurse can best help the staff members cope with the child's demands by encouraging them to do what? a. Provide as many extra treats as possible because the child is dying. b. Set reasonable limits to help the child feel more secure and content. c. Give the child some extra treats so they will feel less anxiety after the child dies. d. Understand that the dying child has unique needs and that special privileges can provide the necessary security.

b. Set reasonable limits to help the child feel more secure and content. Reasonable limits are necessary because they provide security and help keep the child's behavior within acceptable bounds. Relationships, not special privileges, should provide the necessary security. Providing treats is an unrealistic approach that allows the child to manipulate the situation.

A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurse's priority action? a. Call the physician. b. Stop the transfusion. c. Slow the infusion rate. d. Assess the intravenous (IV) site for infiltration.

b. Stop the transfusion. Tingling in the fingers and headache may be an indication of an adverse reaction to the transfusion. The nurse's priority action is to stop the infusion and begin a normal saline infusion at KVO (keep vein open). The client should be assessed—including vital signs—then the physician should be notified. The physician should be called after assessment of the patient and implementation of immediate action to stop the transfusion. Slowing the infusion rate is not appropriate if the patient is experiencing a reaction or suspected of having a reaction. Assessment of the IV site is part of the general patient assessment and is not related to a blood transfusion reaction.

Which work is automatically increased for the delegator when there is a decrease in direct client care? a. Leadership b. Supervision c. Delegation d. Assignment

b. Supervision *After delegating tasks to other members of the health care team, the delegator's care towards the client in a direct way decreases, and the supervisory work of the delegator increases.* Leadership work does not necessarily increase when there is a decrease in direct client care. Delegation and assignment of work does not increase, because the work has already been delegated to another health care team member.

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first? a. Call the laboratory to repeat the test. b. Take vital signs and notify the healthcare provider. c. Inform the cardiac arrest team to place them on alert. d. Take an electrocardiogram and have lidocaine available.

b. Take vital signs and notify the healthcare provider. Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The healthcare provider should be notified because medical intervention may be necessary. A repeat laboratory test will take time and probably reaffirm the original results; the client needs immediate attention. The cardiac arrest team is always on alert and will respond when called for a cardiac arrest. Taking an electrocardiogram and having lidocaine available are insufficient interventions.

Which behavior would the nurse consider suitable for an executive position according to Gardner's tasks of leading/managing? a. To inspire clients/families to achieve their vision b. To assist corporate leaders with planning and priority setting c. To inspire the staff to achieve the mission of the organization d. To ensure that the organizational systems work on the client's behalf

b. To assist corporate leaders with planning and priority setting *According to Gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting. *Leading inspires client/families to achieve their vision. A behavior of the management position is to inspire the staff to achieve the mission of the organization. A behavior of the clinical position is to ensure that the organizational systems work on the client's behalf.

When assessing a client who is receiving palliative care, which question regarding spiritual health is most appropriate? a. "Are you afraid of death?" b. "After hearing about your condition, didn't you lose faith?" c. "What is your source of spiritual strength during hard times?" d. "Let me ask the chaplain to visit you in order to help you cope. "

c. "What is your source of spiritual strength during hard times?" When assessing a client who is receiving palliative care, it is appropriate for the nurse to ask about the client's source of spiritual strength during hard times. This helps the nurse understands the client's spiritual practices, facilitating quality care. The nurse should not ask the client if he or she is afraid of death because this is not supportive. Assuming a client has lost his or her faith upon diagnosis is inappropriate and unsupportive. Because not all clients identify with a religion, it is not appropriate to call the hospital chaplain unless the client requests this.

Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse? a. A 25-year-old man who is mimicking the use of a machine gun in front of the nurse's station b. A 45-year-old man who is sitting quietly in the corner, watching the movements of other clients c. A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients d. A 33-year-old woman who wanders aimlessly around the unit, saying, "I just don't know what to do. I feel so lost."

c. A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients The pacing client is demonstrating increased agitation and poses an immediate threat to the safety of other clients. The behavior requires immediate nursing intervention to prevent injury to herself or others. Although the client mimicking the use of a gun is probably hallucinating, he poses no immediate threat to himself or others. Although the quiet, watchful client may be suspicious, the data given do not indicate that he presents a danger to himself or to others. Although anxious, the client who expresses a feeling of being lost does not represent a threat to herself or others.

Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles

c. Administering fluid replacement As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

What entity outlined the principles of delegation for registered nurses? a. Nurse Practice Act b. Multilevel nursing model c. American Nurses Association (ANA) d. National Council of State Boards of Nursing (NCSBN)

c. American Nurses Association (ANA) *The ANA outlined the principles of delegation for registered nurses.* The Nurse Practice Act of each state examines the value of unlicensed personnel in client care delivery and declares that the importance of delegation decisions is the safety and welfare of the public. The multilevel nursing model consists of registered nurses, licensed practical nurses, and unlicensed nursing professionals. The National Council of State Boards of Nursing (NCSBN) stated that the state boards of nursing should regulate nursing assistive personnel across multiple settings.

Which delegation actions may be performed by unlicensed nursing personnel while caring for a client? Select all that apply. a. Teaching the care plan to the client b. Infusing intravenous fluids into the client c. Asking the client to wash the hands before meals d. Instructing the client to take specific medications e. Instructing the client to wear footwear while walking

c. Asking the client to wash the hands before meals e. Instructing the client to wear footwear while walking *Unlicensed nursing personnel (UNP) can delegate simple and straightforward client teaching, such as asking the client to wash his or her hands before meals and wear footwear while walking.* Complex and multifaceted teaching, such as detailing the care plan to the client, cannot be delegated to a UNP. The UNP has less knowledge and professional skills with which to perform complex procedures such as infusing intravenous fluids into the client and does not have a complete knowledge of medications with which to coach the client about medications.

A client with cancer of the liver has surgery to remove the diseased part of the liver. Postoperatively, the client is transported to the postanesthesia care unit with a T-tube in place. In which site does the nurse expect that this tube will be placed? a. A b. B c. C d. D

d. D D is the common bile duct and is the site at which a T-tube commonly is inserted after gallbladder or liver surgery to ensure common bile duct patency. A is a small bile duct and is not the site at which a T-tube is inserted. B is the hepatic duct and is not the site at which a T-tube is inserted. C is the cystic duct and is not the site at which a T-tube is inserted.

Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? a. Advancing the tube to the original insertion depth if the tube becomes dislodged. b. Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. c. Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. d. Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period.

c. Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.

56. Which anatomic changes result in thermodysregulation in elderly people? Select all that apply. a. Increased metabolic rate b. Increased shivering response c. Decreased circulation of blood d. Decreased number of sweat glands e. Decreased vasoconstrictive response

c. Decreased circulation of blood d. Decreased number of sweat glands e. Decreased vasoconstrictive response As aging occurs, body temperature tends to fluctuate because of the body's decreased ability to regulate its temperature. These fluctuations in temperature occur because of decreased blood circulation, decreased number and efficiency of the sweat glands, and decreased vasoconstrictive response. Increased metabolic rate and shivering response do not result in thermodysregulation; they contribute to fluctuations in the body temperature.

What is the most appropriate communication strategy for the nurse working with adolescents in a clinic in a large city health center? a. Relating on a peer level b. Using typical teenage language c. Establishing a relationship over time d. Having discussions in concrete terms

c. Establishing a relationship over time Several meetings with an adolescent provide an opportunity to develop trust and establish a relationship. Relating on a peer level is unrealistic because the nurse is not an adolescent's peer. Using teenage language is not necessary and may even impede the establishment of a relationship. It is not necessary to use concrete terms, because the adolescent is capable of abstract thought.

What qualities does the professional nurse require to lead, manage, and follow in a team? Select all that apply. a. Being insensitive b. Impeding relationships c. Exercising self-awareness d. Motivating self and others e. Managing emotions in self and others

c. Exercising self-awareness d. Motivating self and others e. Managing emotions in self and others *Managing emotions, such as fear, anxiety, and anger, and responding to those feelings in a healthy manner, as well as avoiding passive-aggressive behavior, are traits that the nurse should have to manage a team. The nurse should have the desire to deepen self-awareness and encourage others to do the same to follow in a team. Motivating or inspiring self and others towards a goal is another quality that the nurse should have to lead a team. *The nurse should be empathetic and able to reveal others' perspective in a situation. Fostering and handling relationships is another one of the abilities the nurse should have when leading and managing a team.

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. What response should the nurse critically assess on this client? a. Edema b. Belching c. Fluid deficit d. Excessive salivation

c. Fluid deficit Dehydration is a danger because of fluid loss with gastrointestinal (GI) suction. Based on the data provided, edema, belching, and excessive salivation are not likely to occur.

Which model of nursing is focused on the task-oriented approach to client care? a. Team model b. Primary model c. Functional model d. Case management model

c. Functional model *The functional model of nursing is a method of providing client care by which each licensed and unlicensed staff member performs specific tasks for a large group of clients.* Team nursing is a small group of licensed and unlicensed personnel, with a team leader, responsible for providing client care to a group of clients. Primary nursing is a model of client care delivery whereby one registered nurse functions autonomously as the client's main nurse throughout the entire hospital stay. Case management is a model of delivering client care based on client outcomes and cost containment.

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? a. Peas b. Corn c. Green beans d. Mashed potato

c. Green beans According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas are a starch and are not an equivalent vegetable substitute for broccoli. Corn is a starch and is not an equivalent vegetable substitute for broccoli. Mashed potato is a starch and is not an equivalent vegetable substitute for broccoli.

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? a. Decreased serum glucose levels b. Decreased serum calcium levels c. Increased blood urea nitrogen levels d. Increased serum bicarbonate levels

c. Increased blood urea nitrogen levels With diabetic ketoacidosis blood urea nitrogen level generally is increased because of dehydration. With diabetic ketoacidosis, the serum glucose levels are generally above 300 mg/dL (16.7 mmol/L). The calcium level is unrelated to diabetic ketoacidosis. Serum bicarbonate levels are below 15 mEq/L (15 mmol/L).

A client says, "Since my husband died I've got nothing to live for. I just want to die." The nurse hears the nursing assistant say, "Things will get better soon." What does the nurse identify this response as? a. Offering advice b. Belittling the client c. Changing the subject d. Providing false reassurance

d. Providing false reassurance False reassurance is an effort to be supportive, often involving the use of clichés, and is not based in fact. Offering advice tells the client what to do; clients should be encouraged to solve their problems. Belittling statements demean the client or minimize client concerns. The nursing assistant's statement did not change the subject.

A client suspected of carcinoma of the liver is scheduled for a liver biopsy. For which procedural contraindication should the nurse assess the client? a. Confusion and disorientation b. Presence of any infectious disease process c. International normalized ratio (INR) greater than 4.5 d. Inclusion of foods high in vitamins E and phytonadione in the client's diet

c. International normalized ratio (INR) greater than 4.5 A normal INR range is 0.7 to 1.8. INR values over 4.5 increase the risk of major hemorrhage. This should be corrected before the biopsy to prevent hemorrhage. Confusion and disorientation are not a contraindication for a liver biopsy; however, if present, the client may need support and the healthcare provider may need assistance, but the biopsy can still be done. A biopsy is not contraindicated in the presence of an infectious disease. Phytonadione (vitamin K) is needed to produce prothrombin; however, this does not guarantee clotting activity because the liver also has to make an adequate supply of clotting factors and proteins for blood clotting to occur. Vitamin E is not involved in blood clotting.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? a. Change the client's diet to bland. b. Obtain a stool specimen for occult blood. c. Prepare for insertion of a nasogastric tube. d. Monitor recent laboratory reports for hemoglobin levels.

c. Prepare for insertion of a nasogastric tube. The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.

What interventions should the nurse perform while caring for an actively dying client? Select all that apply. a. Admit the client in hospice care. b. Perform aggressive laboratory tests. c. Provide client and family reassurance. d. Keep the client undisturbed for long time. e. Perform symptom management in the client.

c. Provide client and family reassurance. e. Perform symptom management in the client. The nurse should provide comfort care in an actively dying client. In comfort care, the nurse should reassure the client and family to reduce their emotional anxiety. The nurse should perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

Which theory states that leaders act as change catalysts and innovators? a. Role theory b. Trait theory c. Quantum theory d. McGregor's Theory X

c. Quantum theory *Quantum theory states that leaders must embrace uncertainty and understand behaviors before changing them. Therefore quantum leaders represent change catalysts and innovators. *Role theory is a collection of concepts that predict circumstances under which certain type behaviors are expected. Trait theory is a leadership theory in which leadership traits such as a certain set of physical and emotional characteristics are innate and cannot be learned. McGregor's Theory X describes the workforce motivation by assuming that people basically do not like their work and must be coerced by their manager to perform.

A nurse encourages employees to implement a Magnet Recognition Program in the organization. The nurses think beyond their own personal needs and are clear about the group outcomes. Which leadership quality according to Gardner's tasks is reflected in the activity of the nurse? a. Developing trust b. Serving as a symbol c. Representing the group d. Achieving workable unity

c. Representing the group *According to Gardner's Tasks of Leadership, encouraging employees to implement a Magnet Recognition Program shows that the nurse is representing the group.* Trust develops when leaders are clear when providing direction and refrain from misdirecting others in their thinking and actions. The leader may serve as a symbol by becoming involved in public relations events, for example. The nurse as leader can achieve workable unity between and among parties by avoiding, diminishing, or resolving conflicts.

The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should instruct the client on which eye problem most associated with diabetes? a. Cataracts b. Glaucoma c. Retinopathy d. Astigmatism

c. Retinopathy Diabetic retinopathy is a leading cause of blindness in diabetics. Glaucoma and cataracts also are associated with diabetes, but retinopathy is the most common eye problem. Astigmatism is not associated with diabetes.

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning? a. White blood cell (WBC) cell count b. Renal ultrasound c. Serum creatinine level d. 24-hour urinary output

c. Serum creatinine level Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a nitrogenous product of protein breakdown, is increased with renal insufficiency. WBC count does not measure kidney function; white blood cells usually are depressed because of immunosuppressive therapy to prevent rejection. WBC count is more valuable for assessing structure than function. Although 24-hour urinary output should be considered, it is not as definitive as the serum creatinine level.

When teaching about aging, the nurse explains that older adults usually have what characteristic? a. Inflexible attitudes b. Periods of confusion c. Slower reaction times d. Some senile dementia

c. Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

Which action of the nurse leader indicates implementing Gardner's task of "explaining"? a. Assisting clients and families in formulating their vision of future well-being b. Providing self-care to enhance the ability to care for staff, clients, and their families c. Teaching and interpreting the information to ensure clients' functioning and well-being d. Assisting clients in sorting out and articulating personal values in relation to health problems

c. Teaching and interpreting the information to ensure clients' functioning and well-being *The nurse leader implements Gardner's task of " explaining" by teaching and interpreting the information that ensures clients' functioning and well-being. *The nurse leader implements Gardner's task of "envisioning goals" by assisting clients and their families in formulating their vision of future well-being. The nurse leader implements Gardner's task of "renewing" by providing self-care to enhance the ability to care for staff, clients, and their families. The nurse leader implements Gardner's task of "affirming values" by assisting clients and their families as they sort out and articulate personal values in relation to health problems.

A 15-year-old with type 1 diabetes has a history of noncompliance with the therapy regimen. What must the nurse consider about the teenager's developmental stage before starting a counseling program? a. They usually deny their illness. b. They have a need for attention. c. The struggle for identity is typical. d. Regression is associated with illness.

c. The struggle for identity is typical. Striving to attain identity and independence are tasks of the adolescent, and rebellion against established norms may be exhibited. Although the adolescent may be using denial, denial is not developmentally related to adolescence. This behavior is not a bid for attention; adolescents want to be like their peers and not stand out. Nor is this behavior regression; regression is the use of patterns of coping associated with earlier stages of development.

A nurse with burnout asks the nurse manager, "What can I do to prevent burnout in the future?" What is the best response by the nurse manager? a. "Hone your problem-solving skills." b. "Ignore situations that can be changed." c. "Improve your time-management skills." d. "Develop a wide variety of coping strategies."

d. "Develop a wide variety of coping strategies." The response "Develop a wide variety of coping strategies" will help the nurse learn how to cope with stress; different defenses can be used in a variety of situations. Problem-solving may identify a problem after it exists; it is not a strategy for preventing a problem. Learning to ignore or avoid people or situations that cannot be changed, not those that can be changed, can help prevent professional burnout. Development of effective time-management skills is just one coping strategy to be used.

A nurse educates a mother about the proper administration of oral medication to her 4-year-old child. What statement made by the mother indicates effective learning? a. "I should administer the medication with a cup or spoon." b. "I should mix the medicine in a large amount of food." c. "I should avoid giving a straw to my child to take pills." d. "I should use a disposable oral syringe to prepare liquid doses."

d. "I should use a disposable oral syringe to prepare liquid doses." The mother should use a plastic, disposable oral syringe to prepare accurate liquid doses, especially those less than 10 mL. The mother should not give medicine through a cup, spoon, or dropper because of the risk of inaccurate measurements. The mother should refrain from mixing the medicine in a large amount of the child's food because the child may refuse to eat such a large quantity. The mother can use straws for her child to swallow pills.

A client with recently diagnosed diabetes states, "I feel bad. My spouse and I do not get along. It seems as though my spouse doesn't care about my diabetes." What is the nurse's best response? a. "You don't get along with your spouse." b. "I'm sorry. What can I do to make you feel better?" c. "It may be temporary because your spouse also needs time to adjust." d. "You are unhappy. I wonder, have you tried to talk to your spouse?"

d. "You are unhappy. I wonder, have you tried to talk to your spouse?" The response "You are unhappy. I wonder, have you tried to talk to your spouse?" identifies the client's feelings and accepts them but also points out the responsibility of the client to take action. Although the response "You don't get along with your spouse" identifies one of the client's concerns, the identification of the underlying feeling is more therapeutic. The response "I'm sorry. What can I do to make you feel better?" makes the nurse responsible for changing the situation, which is not appropriate or therapeutic. The response "It may be temporary because your spouse also needs time to adjust" denies the client's feelings and provides false reassurance.

80. A client has been placed in seclusion as a result of uncontrolled physical aggression directed toward both the staff and another client. In light of the events set forth in the documentation, what should the nurse manager do initially? *Client Documentation* *The client began by pacing and mumbling obscenities shortly after leaving a family group session attended by several of her siblings. Attempts to assist the client in deescalating the behavior proved ineffective. When the client threw several books at another client and then proceeded to kick and spit at staff attempting to remove the client from the day-room, the decision was made to place her in the seclusion room. the staff successfully initiated seclusion at 3:40 pm. The client was medicated with intramuscular promazine in accordance with the health care provider's prescription. the client was check every 15 minutes and her physical needs addressed. Vital signs and behavior were document in accordance with unit policy. The client was able to return to the unit at 5:30 pm after demonstrating the ability to control behavior and respond to staff in a safe manner. * a. Include the client in a discussion with staff regarding the managing of the events. b. Compliment the staff on managing the potentially dangerous situation so therapeutically. c. Question the use of a phenothiazine like promazine to manage aggressive behavior. d. Ask for details regarding how the staff attempted to manage the client before seclusion was initiated.

d. Ask for details regarding how the staff attempted to manage the client before seclusion was initiated. Documentation must include descriptions of attempted interventions that support that the seclusion was the least restrictive management alternative. The client would benefit from a discussion regarding the events leading up to and during the seclusion, and the staff may have managed the event successfully, but there is an omission in the documentation that requires attention and so has priority. Phenothiazines are used to assist in managing such behaviors and were prescribed and administered according to a primary healthcare provider's prescription.

A client has a liver biopsy. Which nursing intervention is appropriate for monitoring or preventing a post-liver biopsy complication? a. Place the client in a left side-lying position. b. Keep the client supine on bed rest for six hours. c. Take the client's pulse and blood pressure every shift. d. Assess the client for pain in the right upper quadrant.

d. Assess the client for pain in the right upper quadrant. If there is bleeding, subcapsular accumulation of blood will occur and cause pressure and pain in the area of the liver. Placing the client in a left side-lying position is to no avail, as the liver is on the right side of the body. A right side-lying or supine position is maintained for one to two hours. Taking the client's pulse and blood pressure every shift is too infrequent. Performing this every 15 minutes for two hours and then every 30 minutes for two hours is more appropriate.

A nurse manager transfers the task of caring for a client who has undergone appendectomy to a registered nurse (RN). Which element of the healthcare system is the RN practicing? a. Delegation b. Leadership c. Supervision d. Assignment

d. Assignment *Both accountability and responsibility are transferred from one person to the other in assignment.* When a nurse manager delegates the task of client care to an RN, responsibility is transferred to the RN. The nurse manager shares accountability with the RN in delegation. The nurse manager, as leader, manages the healthcare team and delegates tasks to members of the healthcare team. In supervision, the nurse manager oversees the RN in completing the task.

After 3 weeks of mental health therapy a client tells the nurse, "I feel ready to go home." How can the nurse best evaluate the client's readiness for discharge? a. By questioning the client's level of trust in self and staff b. By requiring the client to explain any changes in behavior since admission c. By asking the client to identify specific behaviors as examples of wellness d. By having the client's family and friends provide feedback about changes in behavior

d. By having the client's family and friends provide feedback about changes in behavior Asking clients to identify positive changes can reinforce those changes and help the client prepare for discharge. Questioning the client's level of trust in self and staff may be viewed as a lack of trust and undermine readiness for discharge. Pressuring the client to explain behavioral changes increases anxiety and the need to use defenses. Information received from family and friends is not as relevant as the client's perceptions of progress.

The nursing manager reviews client case studies to create a report that identifies medical errors that occurred in the hospital during the previous two years. Which case study would the nursing manager identify as a sentinel event? a. *Case study 1* Patient Details: The patient with leukemia was on anticancer therapy--Patient finding: The patient had decreased white blood cells. The patient also reports hair loss after initiating the therapy b. *Case study 2* Patient details: Pt scheduled for surgery on the left leg--Pt Findings: Pt's right right leg was prepped for surgery. During a final pre-op check, it was discovered that the X-ray film was accidentally reversed. Surgery was performed on the left leg. c. *Case study 3* Pt details: pt with diabetes was on insulin therapy (Humulin N)--Pt findings: Pt had seizures due to an overdose of insulin (Humulin N) d. *Case study 4* Pt details: Pt with congestive heart failure is on intravenous digoxin (Cardoxin) therapy

d. Case study 4 Sentinel event is a serious adverse event involving the death of the client due to medical error. Therefore the nurse manager will identify the death of a client due to overdose of digoxin (Cardoxin) as a sentinel event. So, from the chart above it is implied that case study 4 is an example of a sentinel event. A decrease in white blood cells and hair loss are common findings in the client who is receiving chemotherapy. Therefore the nursing manager will not identify case study 1 as a sentinel event. A near miss is an unplanned event that did not result in injury, illness, or damage, but that had the potential to do so. In case study 2, the healthcare providers, before surgery began, realized that the wrong leg had been prepped; the error did not reach the client. Therefore it is an example of a near-miss event. The medication errors that cause moderate harm, but not the death of a client, are classified as an adverse event. In case study 3, the overdose of insulin (Humulin N) resulted in seizures but not the death of the client. Therefore it is an example of an adverse event.

The nurse is caring for four different clients with different health conditions. Which client care task delegated to the licensed vocational nurse (LVN) would be appropriate to develop a suitable care outcome? a. Client 1--Lobectomy--Writing Nursing care plan b. Client 2--Vasectomy--providing IV fluids every 2 hrs c. Client 3--Nephrectomy--Performing continuous peritoneal dialysis d. Client 4--Hysterectomy--Providing oral medication twice a day

d. Client 4--Hysterectomy--Providing oral medication twice a day Providing oral medication to the client who has undergone hysterectomy can be done by the licensed vocational nurse (LVN). The LVN is not eligible to write a nursing care plan for the client with hysterectomy; this must be performed only by the registered nurse (RN). An LVN cannot provide intravenous fluids. Continuous peritoneal dialysis is not performed by an LVN; this procedure requires a more experienced practitioner such as an RN. Different tasks are performed by different healthcare professionals. Try to recollect eligibility criteria of LVN to answer the question. A licensed practical nurse (LPN) can perform only specific tasks. Answer the question based on the given condition.

On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, and barely has basic needs attended. The client is the primary caregiver for the infant. What should the nurse do? a. Advise the purchase of appropriate toys designed for this age level. b. Inform the client that the child will be cognitively impaired if he is not stimulated. c. Explain the need for the family to hire a mother's helper for the home. d. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference.

d. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference. initiating a referral to an appropriate agency to assess the need for a home health aide and scheduling a family meeting will ensure that a thorough assessment of the family's needs is made and the appropriate assistance initiated. Advising that the client purchase toys designed for this age level is inadequate; in addition, household objects can serve as well as store-bought toys. Informing the client that the child will be cognitively impaired if not stimulated may frighten the client and precipitate feelings of guilt. Explaining the need for the family to hire a mother's helper for the home is premature and may or may not be necessary.

Which nursing action during a psychosocial assessment of a transgender client may contribute to health disparities? a. Asking specific questions about gender and sexual practices used b. Reporting any physical or mental abuse of the client to the appropriate authority c. Assuring the client that the confidentiality of the information gathered during the assessment will be maintained d. Insisting on using the name listed on the client's driver's license

d. Insisting on using the name listed on the client's driver's license Insisting on referring to the client in a different way than the client self-identifies erodes client trust and alienates the client, which may make him or her less willing to seek care, contributing to health disparities. The nurse can ask specific questions about gender and sexuality if these are relevant to the client's health and can help determine how these factors may affect care. Evidence of abuse is to be reported to the appropriate authority in accordance with the law. The client should be assured that the assessment responses are confidential and would not be shared with anyone, even family, friends, or significant others without the client's permission

While organizing a community health care program for polio vaccinations, the registered nurse delegates the task of administering vaccines to the members of the health care team. Who among the health care team is most suitable to carry out the task? a. Technician b. Patient care associate c. Certified nursing aide d. Licensed practical nurse

d. Licensed practical nurse *The licensed practical nurse can be delegated the task of administering oral medications or vaccines.* Technicians, patient care associates, and certified nursing aides are unlicensed assistive personnel who are not appropriate for delegation of tasks such as administering medication or vaccines as per the delegation rights. The scope of practice for unlicensed assistive personnel providing client care is limited to providing basic care, comfort, and hygiene.

Which term refers to the nurse's ability to plan, direct, control, and evaluate others in different situations? a. Delegation b. Leadership c. Followership d. Management

d. Management *Management is defined as the ability to plan, direct, control, and evaluate the nurse staff in various situations.* Delegation is the transfer of authority to perform some type of task or work. Leadership can be defined as the use of individual traits and abilities in relationship to others and the ability to interpret the context where a situation is emerging. Followership is that each member of a team contributes optimally, but acquiesces to a leader or manager to ensure the best clinical decision-making.

The nursing manager said, "Nurse leaders must also be excellent change managers." Which statement supports this? a. Nurse leaders ensure a change that will support only staff. b. Nurse leaders are only coordinators to bring a change in the system. c. Nurse leaders can only support clients in changing their behaviors to improve care. d. Nurse leaders will ensure that the disruption and chaos of change does not affect client care.

d. Nurse leaders will ensure that the disruption and chaos of change does not affect client care. *During change, nurse leaders keep the delivery of safe and effective care at the center of their attention to ensure that the disruption and chaos of change do not affect clients.* By supporting a transparent and evidence-based environment, the nurse leader ensures a culture that will support both clients and staff during the change process. Nurse leaders play the roles of both coach and coordinator, facilitating the changes needed at a system, unit, or team level. Nurse leaders not only support clients in changing their behavior but also must foster innovation and promote change in the workplace that advance client safety and improves client outcomes.

A client is brought to the emergency department by her husband. He is upset and says, "She fainted in the kitchen. I'm so worried about her, because she's going to kill herself if she keeps this up." A history is obtained from the husband, and the vital signs and physical assessment data are collected by the nurse. What should the nurse do next? *vital signs* Temperature 97F (36.1 C) Pulse: 60 bpm; regular rhythm Respiration: 18 bpm, regular depth Blood Pressure: 98/62 *Physical Assessment* Height: 5'9" WT: 90 lbs Appearance: Cachexia; sunken eyes; protruding bones; dry skin; languo on face and body; decreased muscle tone ECG: Normal sinus rhythm, depressed T waves *History from husband* Purges 3 to 5 time per day Exercises an hour before and 2 hours afer work Take 5 laxatives er day Menses stopped 3 months ago "Eats tiny amounts f food" a. Offer her a small sandwich. b. Auscultate the abdomen for bowel sounds. c. Administer oxygen by way of nasal cannula. d. Obtain a blood specimen for serum electrolytes.

d. Obtain a blood specimen for serum electrolytes. The client has been taking laxatives and purging, and vomitus and feces are high in potassium. Hypokalemia is associated with decreased muscle tone and depressed T waves on an electrocardiogram. A blood specimen should be sent to the laboratory for analysis of serum electrolytes. Offering the client a small sandwich is not the priority, and the client probably will not eat the sandwich. The client is not exhibiting signs of respiratory distress. The respiratory rate is within the expected limits, and there is no indication of dyspnea. There are no data to indicate that the client has a gastrointestinal problem. The malnutrition is related to not eating rather than to a problem with the absorption of nutrients. If the client is taking five laxative pills a day, bowel sounds probably will be hyperactive.

An unmarried pregnant client who is attending a crisis intervention group has finally decided to go through with the pregnancy and keep the baby. What is the crisis intervention nurse's primary responsibility at this time? a. Confirming that this really is what the client wants to do b. Exploring other problems that the client may be experiencing c. Selecting a primary healthcare provider that the client can visit for prenatal care d. Providing information about resources from which the client may receive assistance

d. Providing information about resources from which the client may receive assistance After the client has made a decision, the nurse's main responsibility is to assist the client in using the problem-solving process to explore other agencies, facilities, and services. It is not appropriate to question the decision after it has been made. Exploring other problems that the client may be experiencing is not part of the immediate goal during the crisis; the client may be encouraged to seek help later for other problems. The client must take primary responsibility for selecting a primary healthcare provider for prenatal care.

A nurse is developing a discharge plan for a client hospitalized with severe cirrhosis of the liver. What should be included in this plan? a. The need for a high-protein diet b. The use of a sedative for relaxation c. The need to increase fluids d. The importance of reporting personality changes to the primary healthcare provider

d. The importance of reporting personality changes to the primary healthcare provider The damaged liver may cause increased ammonia levels, resulting in central nervous system (CNS) irritation, which produces behavioral changes. A damaged liver does not metabolize protein adequately; a low-protein diet is indicated. Sedatives are detoxified by the liver and are contraindicated in severe hepatic disease. Kidney function usually is not affected.