RN Leadership Online Practice 2023 A
A charge nurse is assisting with the care of a client. Which of the following findings should the charge nurse identify that the client is experiencing an adverse reaction and requires notification of provider and updating the client's plan of care? Select 6 findings that indicate that client is having an adverse reaction.
blood pressure, temperature, heart rate, respiratory rate, pain level, report by the client
A nurse is working in the emergency department when there is an explosion in a local chemical plant. Multiple victims are expected at the facility. Which of the following should be the nurse's priority intervention upon client arrival?
Isolate the clients and irrigate with water
A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?
LPNs provide care to class II (green tag) clients
A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?
Perform a chart review to gather data about the clients who developed infections
When participating in the informed consent process prior to surgery, which of the following actions should the nurse take?
Review previously provided information about the procedure
A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse take? Select all that apply.
Role model a positive approach to the changes, encourage staff members who support the changes to discuss the issue with resistant staff
A nurse is caring for a client who is experiencing adverse effects after receiving a new medication. Which of the following communication tools should the nurse use for management of this complication?
SBAR framework
A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives?
"A family member of a client can have the living will overturned in some cases."
A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions?
"After I finish with the printout of my assignment, I'll put it in the shredder receptacle."
A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Clients on a mental health unit can refuse their medication."
A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing about the failure of the AP to restock unit supplies. The AP leaves the room. Which of the following statements should the nurse manager make to the newly licensed nurse?
"I would like for you to approach the AP to resolve the problem."
A nurse is teaching a newly licensed nurse about using electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"My access to client electronic records might be tracked by my nurse manager."
A charge nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates the teaching was effective?
"There must be documentation in the medical record about whether a client has advance directives."
A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?
"Your case manager will coordinate the resources you will need."
A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?
A client admitted for a fractured hip who has developed slurred speech
A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of causalities. Which of the following clients should the nurse recommend the provider evaluate first?
A client who has a sucking chest wound
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?
A client who has peripheral vascular disease and has an absent pulse in the right foot
A home health nurse is planning daily visits and receives laboratory results for 4 adult clients. Which of the following clients should the home health nurse plan to visit first, based on their laboratory findings?
A client who is 3 days postoperative and has a platelets 100,000/mm3 (150,000 to 400,000/mm3)
A nurse has just received a report on four clients on a medical-surgical unit. Which of the following clients should the nurse plan to assess first?
A client who is postoperative following a total knee arthroplasty and has a capillary refill of 4 seconds
A nurse manager is reviewing recent actions by staff to determine adherence with HIPPA guidelines. Which of the following actions by a nurse should the manager identify as adhering to HIPPA guidelines?
A nurse shares a client's test results with an AP on the same nursing team
A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?
Advise the client to install grab bars in the bathroom at home
A nurse manager is presenting an in-service about preventing readmission of clients due to complications following joint arthroplasty. Which of the following leadership tasks is the nurse performing?
Advocacy
A charge nurse is supervising a team of licensed practical nurses (LPNs) and assistive personnel (AP). The charge nurse should intervene in which of the following situations?
An LPN develops the nursing plan of care for a client who has pneumonia
A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?
Ask the client to explain the procedure that is being performed
A charge nurse is observing a newly licensed nurse care for a client who has a prescription for application of an aquathermia pad to the right lower leg. Which of the following actions should indicate to the charge nurse that the nurse understands how to use the device? Select all that apply.
Asks the client to report if the aquathermia pad gets too warm, ensures that the client's call light is in reach
A charge nurse is delegating tasks on nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the charge nurse take?
Assign the procedure to a licensed practical nurse (LPN)
A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease?
Chlamydia trachomatis
A nurse manager is assessing incident reports for the unit. Which of the following client's medical records indicate professional negligence? Select 2 clients that the nurse manager should recognize have charts that indicate professional negligence.
Client 4, Client 5
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?
Compare data from clients' records regarding skin integrity with established criteria
An RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of the following activities must be performed by the RN?
Completing the client's initial admission assessment
A charge nurse has been asked to determine staff adherence to establish standards for postoperative vital sign measurement. Which of the following actions should the nurse take to collect information?
Conduct a retrospective chart audit of all surgical clients for the past 6 months
A nurse case manager is planning a teaching session on the use of critical pathways with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching?
Critical pathways prevent unnecessary expense
A nurse manager is reviewing client care needs. Which of the following actions should the nurse take when making client care assignments? Select all that apply.
Delegate provider prescription received for client 1 to a registered nurse, delegate provider prescription received for client 3 to a practical nurse, delegate provider prescription received for client 4 to an assistive personnel
A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?
Determine a client's intake and output
A nurse is observing an assistive personnel (AP) who is caring for a group of clients. Which of the following actions by the AP demonstrates effective use of time management skills in providing client care?
Grouping activities for several clients in the same location
A grandparent brings their 15-year-old grandchild to the emergency department reporting that they have severe abdominal pain and are scheduled for an immediate appendectomy. The nurse confirms that the client's guardians are unavailable. Which of the following actions is appropriate?
Have the grandparent sign the consent form
A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?
Home health
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?
Inform the assistive personnel (AP) of the client's weight-bearing status
A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that they are leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next?
Inform the client about the risks they may encounter by leaving the facility
A charge nurse on a medical unit hears the fire alarm and announcement that a fire is occurring on the unit. Which of the following is the priority action by the charge nurse?
Instruct ambulatory clients to go to a safe area
A nurse in a long-term care facility is transferring a client to an acute-care facility. Which of the following information should the nurse include when transferring?
List of current medications
A charge nurse on a maternal newborn unit is receiving change of shift charge nurse report for a group of newborns. Which of the following 3 newborns should the charge nurse identify as requiring priority care? Select 3 newborns the charge nurse should identify as priority.
Newborn 5, Newborn 3, Newborn 1
A newborn is being discharged from the hospital. Which of the following is the best action for the nurse to take to ensure the newborn's safety?
Observe the parent securing the newborn into the infant care seat in the parent's car
A nurse is caring for four clients. Which of the following tasks can the nurse assign to an assistive personnel (AP)?
Perform chest compressions on a client who is in cardiac arrest
A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?
Pick up the first sterile glove by grasping the folded cuff edge
A nurse is caring for a client. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? select all that apply
Place an absorbent pad on the client's bed, report the client's blood pressure to the nurse, apply barrier cream to the client's buttocks, document the client's vital signs
A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include?
Raise the footplates of the wheelchair before transferring the client
A charge nurse on a medical-surgical unit is making assignments for the next shift. A licensed practical nurse (LPN) and an assistive personnel (AP) are members of the team. Which of the following client care assignments should the nurse assign to the LPN?
Reinforcing teaching to a client
A charge nurse is assessing a client in a long-term care facility. Which of the following findings indicate that a referral for a speech pathologist is needed? Select all that apply.
Speech coordination findings, cough findings, vocal characteristics during mealtime, observation of food pocketing
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when the rate was set at 100 mL/hr. After notifying the provider and verifying that the pump was properly programmed, which of the following is the nurse's priority?
Tag the pump for maintenance and acquire a new pump for the client
A nurse is presenting information on health care law to a group of newly licensed nurses. Which of the following information should the nurse include?
The Patient Self-Determination Act (PSDA) requires a nurse to give clients information about end-of-life options
A nurse is developing a plan of care for a school-age child whose family is without housing. Which of the following findings should the nurse identify as the priority?
The child has red fissures at the corners of the mouth
A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?
The client refuses to attend physical therapy sessions
A nurse manager is planning an educational program about the role of the nurse as a client advocate. Which of the following should the nurse include in the presentation?
The distribution of confidentiality disclosure information to clients
A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? Select all that apply.
The right to be treated with respect and dignity, the right to refuse their medications, the right to leave regardless of provider recommendations, the right to be fully informed of their health conditions
A nurse is caring for a client who speaks only Spanish and is to undergo hip arthroplasty the next day. The client's child speaks English and is in the room with them. Which of the following actions should the nurse take? Select all that apply.
Use a Spanish/English medical dictionary to assist with communication, enlist the help of the bilingual assistive personnel (AP) assigned to the client, request that the hospital's Spanish interpreter help the nurse provide education
A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. Which of the following should the nurse manager include in the teaching?
Verify that a provider prescription is in the medical record for clients who have restraints
A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?
Wear an N95 respirator mask when in the client's room
There has been a community disaster and stable clients must be discharged from a facility to prepare for the influx of new casualties. A nurse should identify that which of the following clients is safe to discharge?
a client who has multiple sclerosis and reports ataxia
A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? select all that apply
ambulating a client who uses a walker, adding thickener to thin liquids on a client's food tray