Saunders Leadership/Management

A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1. Assault 2. Battery 3. Slander 4. Invasion of privacy

1. Assault Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

The nurse calls a client's health care provider (HCP) to report that the client, who has heart failure, is demonstrating increased wheezes on lung auscultation and dyspnea. The HCP is in a hurry because of involvement in a critical care situation in the hospital emergency department and gives the nurse a telephone prescription for furosemide. Afterwards, the nurse realizes that the route of the medication is unclear. Which action by the nurse is the most appropriate? 1. Call the HCP who gave the telephone prescription and clarify the prescription. 2. Call the nursing supervisor for assistance in determining the route of the medication. 3. Administer the medication by the intravenous route because this route usually is used for clients with heart failure. 4. Administer the medication by the oral route, and clarify the prescription once the HCP has finished addressing the critical care issue in the emergency department.

1. Call the HCP who gave the telephone prescription and clarify the prescription. Telephone prescriptions involve an HCP stating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the HCP. The nurse then writes the prescription on the HCP's prescription sheet. Under no circumstances would the nurse try to interpret an unclear prescription or administer a medication by a route that was not prescribed. The nurse must call the HCP who gave the telephone prescription and clarify the prescription.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4. Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1. Call the nursing supervisor to activate the agency disaster plan. In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Cleaning a client's dentures 2. Ambulating a postoperative client 3. Taking 4:00 p.m. vital signs on clients 4. Giving medications left by the nurse for the client to take 5. Assisting a client with a urinary drainage catheter into a chair 6. Obtaining a catheterized urinalysis and taking it to the laboratory

1. Cleaning a client's dentures 2. Ambulating a postoperative client 3. Taking 4:00 p.m. vital signs on clients 5. Assisting a client with a urinary drainage catheter into a chair Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the UAP; therefore, these options are incorrect. The remaining options identify activities that can be performed by the UAP.

A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the unlicensed assistive personnel (UAP)? Select all that apply. 1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to his transportation to home 4. Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5. Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids

1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Accompanying a client being discharged to his transportation to home Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. Based on the options provided, the most appropriate activities for a UAP are noted in options 1, 2, and 3. These options do not include situations to indicate that these activities carry any risk. Because the client needs to eat lying flat, the client is at risk for aspiration. Care related to IV therapy needs to be done by a licensed nurse.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's health care provider (HCP). 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.

1. Contact the client's health care provider (HCP). In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the HCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

The nurse is developing a client care assignment for a group of unlicensed assistive personnel (UAPs). What is the nurse's first step in planning and assigning clients? 1. Determine what skills can be delegated. 2. Determine the years of experience of each UAP. 3. Determine how much supervision is required for each client assigned. 4. Determine how many clients the agency allows to be delegated to each UAP

1. Determine what skills can be delegated. Knowing what skills can be delegated is essential when nurses assign client care to other health care personnel. Nurses must be familiar with their state's Nurse Practice Act, institutional policies and procedures, and the institution's job description for UAPs. Information from these sources is necessary to define the level of competency of UAPs. Determining how many clients to delegate is not the first step, and in fact most agencies do not state a specific number of clients that may be assigned. Determining years of experience is also not a first step, although a UAP's experience could affect the type of client assigned. How much supervision will be required is also important but, again, not the first step the nurse takes when delegating client assignment to the UAPs.

The nurse is acting in the role of client advocate in which situations? Select all that apply. 1. Promoting client comfort 2. Demonstrating mutual respect for all nurses 3. Questioning health care provider prescriptions 4. Supporting a client decision regarding a health care choice 5. Speaking at a continuing education offering in the community

1. Promoting client comfort 3. Questioning health care provider prescriptions 4. Supporting a client decision regarding a health care choice A client advocate is a person who speaks out for or supports the best interests of the client. This includes encouraging independence in addition to speaking for the client. Demonstrating mutual respect for all nurses and speaking at a continuing education offering does not relate to client advocacy.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1. The acuity level of the clients 5. Client needs and workers' needs and abilities There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims, "My baby is not moving." 2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3. A young child standing next to an adult family member who is screaming, "I want my mommy!" 4. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? 1. A client requiring frequent ambulation 2. A client scheduled for a cardiac catheterization 3. A client requiring range-of-motion (ROM) exercises 4. A client with a 24-hour urine collection who is on strict bed rest

2. A client scheduled for a cardiac catheterization The RN is legally responsible for client assignments and must assign tasks according to the guidelines of Nurse Practice Acts and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The UAP has been trained to care for a client on bed rest and on urine collection, provide assistance with ambulation, and perform ROM exercises. The RN would provide instructions to the UAP regarding the tasks, but the tasks required for these clients are within the role description of a UAP.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client scheduled to receive parenteral nutrition 2. A client who requires assistance with ambulation every 4 hours 3. A client scheduled for discharge who needs teaching about medications 4. A client with bladder cancer who is scheduled for a cardiac catheterization

2. A client who requires assistance with ambulation every 4 hours The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a UAP would be to care for a client on bed rest who requires assistance with ambulation every 4 hours. The UAP is trained in this procedure. The client receiving parenteral nutrition and the client scheduled for a cardiac catheterization require the assessment skills that a licensed nurse can perform. Teaching needs to be done by the licensed nurse. The UAP does not have the education to teach a client about medications.

A woman with left-sided weakness needs assisted living. The woman's family plans to sell her home to pay for assisted living, but the woman refuses to sell because she feels that her family should pay the expenses. What should the nurse do at this time? 1. Carefully explain the woman's wishes to the family. 2. Ask the woman to share experiences about the house. 3. Arrange a meeting between the children and the woman. 4. Suggest using a power of attorney to deal with the children.

2. Ask the woman to share experiences about the house. The nurse should ask the woman to share experiences about the house and act as her advocate. Listening to the woman helps the nurse to gather additional data, enhance the therapeutic relationship by preserving autonomy, and possibly help solve the problem. The woman has not asked the nurse to intervene on her behalf with the family, so explaining the woman's wishes to the family is not indicated. Also, arranging a meeting ignores her autonomy and forces the woman and family to confront one another. The nurse only arranges a meeting after the woman requests or agrees to it. Suggesting a power of attorney is counterproductive to advocacy.

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2. Battery 3. Assault 5. False imprisonment False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. Refuse to float to the ICU based on lack of unit orientation. 2. Clarify with the team leader to make a safe ICU client assignment. 3. Ask the nursing supervisor to review the hospital policy on floating. 4. Submit a written protest to nursing administration, and then call the hospital lawyer.

2. Clarify with the team leader to make a safe ICU client assignment. Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client? 1. Apply the restraint anyway. 2. Contact the health care provider (HCP). 3. Compromise with the client and then apply the restraint. 4. Medicate the client with a sedative and then apply the restraint.

2. Contact the health care provider (HCP). The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and a prescription needs to be obtained from the HCP. The HCP's prescription protects the nurse from liability. The nurse should explain to the client and family the reasons why the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied the restraint on a client who was refusing, the nurse could be charged with battery. Compromising with the client is unethical.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. 1. Document a late entry in the client's record. 2. Draw 1 line through the error, initialing and dating it. 3. Try to erase the error for space to write in the correct data. 4. Use whiteout to delete the error to write in the correct data. 5. Write a concise statement to explain why the correction was needed. 6. Document the correct information and end with the nurse's signature and title.

2. Draw 1 line through the error, initialing and dating it. 6. Document the correct information and end with the nurse's signature and title. If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.

The registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN notes the LPN performing which action? 1. Assisting the client to ambulate 2. Elevating the knee gatch on the client's bed 3. Performing range-of-motion exercises to the client's legs 4. Removing the antiembolism stockings during morning care

2. Elevating the knee gatch on the client's bed After a vaginal hysterectomy, the client is at risk for deep vein thrombosis or thrombophlebitis. The nurse should implement measures that prevent this complication. Range-of-motion exercises, antiembolism stockings, and ambulation are important measures to prevent this complication. Antiembolism stockings are removed to provide hygiene care and are then replaced. If the RN notes that the LPN used the knee gatch on the bed, the RN should intervene. This action would inhibit venous return, increasing the risk for deep vein thrombosis or thrombophlebitis.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.

2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? 1. Requires that 1 nurse take care of 1 client 2. Promotes appropriate use of hospital personnel 3. Requires a case manager who plans the care for all clients 4. Uses a team approach, but 1 nurse supervises all other employees

2. Promotes appropriate use of hospital personnel Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources; its aim is to maximize hospital revenues while providing for optimal outcomes of care. Case management manages client care by managing the client care environment. Options 1, 3, and 4 are not characteristics of case management.

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an unlicensed assistive personnel (UAP)? 1. Determining if the client has consistently been medication compliant 2. Providing distraction for the client by engaging the client in a board game 3. Discussing the frequency and duration of the hallucinations with the client 4. Assisting the client in identifying any new stressors he or she may be experiencing

2. Providing distraction for the client by engaging the client in a board game Although all of the options represent appropriate interventions, UAPs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the UAP. The other options, assessing medication compliance, the characteristics of the hallucinations, and stressors, are nursing responsibilities and may not be delegated to a UAP.

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical (vocational) nurse, and 2 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. The client who requires a 24-hour urine collection 2. The client with an abdominal wound requiring frequent wound irrigations 3. The older client requiring assistance with a bed bath and frequent ambulation 4. The client on a mechanical ventilator requiring frequent assessment and suctioning

2. The client with an abdominal wound requiring frequent wound irrigations When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The licensed practical (vocational) nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. Collecting 24-hour urine and helping with a bed bath and frequent ambulation can most appropriately be assigned to the UAPs. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN.

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1. "The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2. "If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4. "You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

3. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." Option 3 describes legitimate power. Legitimate power is based on a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management has the responsibility to see that the mandate is met. Option 1 demonstrates informational power. The manager is using data to drive compliance with the mandate. Option 2 reflects an example of coercive power. Coercive power is a "do this or else" type of approach. Option 4 reflects expert power. The manager is asking the staff nurses to comply with the mandate because the manager possesses expert knowledge and skill levels. In addition to coercive, informational, expert, and legitimate power, the manager has referent, reward, and personal power.

The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made? 1. "Any discrepancies in a count will be reported immediately." 2. "I will record each dispensing of an opioid on the special opioids inventory record." 3. "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift." 4. "Opioids will be counted each time one is removed from the drawer and at the end and beginning of each shift."

3. "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift." If the nurse gives a portion of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. Both nurses must sign the form. Leftover portions of an opioid are not saved for use at a later time. The statements in the remaining options are accurate.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the incident. 4. Call the laboratory and ask for the name of the individual who sent the photograph.

3. Call the nursing supervisor and report the incident. Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor. Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1. The client receiving a heparin infusion 2. The client receiving a blood transfusion 3. The client receiving continuous oxygen at 2 L/min 4. The client recovering from Guillain-Barré syndrome 5. The client who just returned from surgery for a hip repair 6. The client on isolation for methicillin-resistant Staphylococcus aureus

3. The client receiving continuous oxygen at 2 L/min 4. The client recovering from Guillain-Barré syndrome 6. The client on isolation for methicillin-resistant Staphylococcus aureus UAPs cannot be assigned to a client requiring care that is more than basic. UAPs do not have the education to safely care for clients requiring more than basic care. Assigning a UAP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).

The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? 1. The client with severe pain related to osteoporosis 2. The client with hypokalemia related to diuretic therapy 3. The client with thrombocytopenia related to chemotherapy 4. The client with an elevated white blood cell count related to infection

3. The client with thrombocytopenia related to chemotherapy The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1. The informed consent does not need to be obtained. 2. The informed consent should be obtained from the family. 3. The informed consent needs to be obtained from the client. 4. The health care provider will provide the informed consent.

3. The informed consent needs to be obtained from the client. Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chickenpox 4. The nurse who never had German measles 5. The nurse who never received the varicella-zoster vaccine

3. The nurse who never had chickenpox 5. The nurse who never received the varicella-zoster vaccine The nurses who have not had chickenpox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh, really? I will discuss this situation with your son." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends who can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4. "I will call the nursing supervisor to seek assistance regarding your request." Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by UAP. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP), which is the best client for the LPN? 1. A client requiring frequent temperature checks 2. A client requiring assistance with ambulation every 4 hours 3. A client on a mechanical ventilator requiring frequent assessment and suctioning 4. A client with a spinal cord injury requiring urinary catheterization every 6 hours

4. A client with a spinal cord injury requiring urinary catheterization every 6 hours When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the UAP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)

4. A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.

Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and should plan to best deal with this difficulty by doing what? 1. Ignoring the resistance 2. Discarding all paper-type documentation forms 3. Demanding that the nurses use the new computer system 4. Allowing the nurses extra time to work with the new computer system

4. Allowing the nurses extra time to work with the new computer system Allowing the nurses extra time to work with the new computer system will alleviate anxiety. Ignoring the issue will not address the problem. Discarding all paper-type documentation forms may cause anxiety in the nurses, particularly if the nurses are uncomfortable with the computer system. Demanding that the nurses use the new computer system may cause resentment and resistance.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.

4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1. Wash the burn site. 2. Apply 1/16-inch (1.5 mm) film directly to the burn sites. 3. Apply the medication with a sterile gloved hand. 4. Apply saline-soaked dressings over the medication.

4. Apply saline-soaked dressings over the medication. Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned.

A health care provider (HCP) asks the nurse to discontinue tube feeding in a client who has a terminal condition. The HCP tells the nurse that the request was made by the client's spouse and children. What should the nurse check for first before carrying out the prescription? 1. Court approval to discontinue the treatment 2. Approval by the institutional ethics committee 3. A written prescription by the HCP to remove the tube 4. Authorization by the family to discontinue the treatment

4. Authorization by the family to discontinue the treatment The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the HCP writes the prescription. Generally, the family makes decisions in collaboration with HCPs and other health care workers and with other trusted advisers. Therefore, the remaining options are incorrect. Court approval may be necessary if a conflict exists or if there is no legal guardian to make the decision. The institutional ethics committee presents acceptable choices or options, but approval by this committee is not necessary

The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is most appropriate? 1. Refuse to float to pediatrics. 2. Convince another nurse to float to the pediatric unit. 3. Tell the supervisor that she needs to go home because of illness. 4. Call the nursing supervisor to discuss the request to report to pediatrics.

4. Call the nursing supervisor to discuss the request to report to pediatrics. Floating may be acceptable legal practice used by hospitals to solve their understaffing problems, enhance efficiency, and reduce staffing costs. Usually the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or unless the nurse can prove lack of knowledge for the performance of assigned tasks. When met with this situation, the nurse should set priorities and identify potential areas of harm to the client. Nurses must be aware of state statutes and case law when asked to perform services outside of their usual area of practice. The nurse should never perform tasks or render services when he or she lacks the knowledge and skill to act competently. It is not appropriate to attempt to convince another nurse to go to the pediatric unit. Option 3 also is an inappropriate action. Among the options presented, it is most appropriate to discuss the situation with the supervisor.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? 1. Ignore the resistance. 2. Exert coercion on the UAP. 3. Provide a positive reward system for the UAP. 4. Confront the UAP to encourage verbalization of feelings regarding the change.

4. Confront the UAP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically.

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4. Every 30 minutes The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity. 2. Remove jewelry and constricting clothing from the victim. 3. Place the extremity in a position so that it is below the level of the heart. 4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4. Move the victim to a safe area away from the snake and encourage the victim to rest. In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity at the heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.

A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? 1. Private room 2. Semiprivate room 3. 4-bed ward room 4. Contact isolation room

1. Private room ASDs are complex neurodevelopmental disorders of unknown etiology composed of qualitative alterations in social interaction and verbal impairment with repetitive, restricted, and stereotype behavioral patterns. Children with ASDs are unable to relate to persons or respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with an ASD needs decreased stimulation, with limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and 4-bed ward rooms would be too stimulating for the child with an ASD. ASD is not a disorder that requires contact isolation

The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? 1. Remove the IV catheter. 2. Apply a warm compress. 3. Check for a blood return. 4.Measure the area of infiltration.

1. Remove the IV catheter. Blanching, coolness, and edema of the IV site all are classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the nurse should remove the IV catheter to prevent any further damage. Warm compresses may be applied to the infiltrated area only after the IV catheter is removed and only if the infiltrated solution is not damaging to the surrounding tissues. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Measuring the area of infiltration would be done after the IV catheter has been removed to assess for any further tissue damage.

A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs further teaching before giving informed consent to the procedure? 1. "If I don't have this surgery, then the tumor will grow." 2. "I know my surgeon explained it, but I still don't know why surgery is needed." 3. "You said my surgeon will remove the tumor but will not be removing the entire breast." 4. "I'll have some pain after the surgery, but it should get better with that tumor gone."

2. "I know my surgeon explained it, but I still don't know why surgery is needed." Informed consent must be obtained before surgery can be legally performed. The nurse acts as an advocate to make sure that the client understands what the health care provider has explained about the surgery. The client must receive information about the purpose of the surgery, other options if surgery is not done, risks of surgery, and benefits of surgery. Options 1, 3, and 4 identify an understanding by the client, whereas option 2 indicates that the client needs more information.

The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 1. Set priorities for the client. 2. Assess the client's readiness to learn. 3. Find out whether anyone lives with the client. 4. Use only 1 teaching method to prevent confusion.

2. Assess the client's readiness to learn. Until the client is ready to learn, teaching sessions will be ineffective. Teaching should be in short sessions, early in the day, when the client is well rested. It is important to include the client in the development of the teaching plan and to set priorities with him or her. Although it may be important to determine whether anyone lives with the client, this is not the initial nursing action. Varied teaching methods are best, such as verbal instruction with visual aids and the provision of written material for later reference.

The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? 1. Obtaining the client's vital signs 2. Positioning the client on the left side 3. Providing the client with reading materials 4. Assisting the client to drink sips of fluid as prescribed

2. Positioning the client on the left side A client who has undergone a renal biopsy should be positioned on the affected side or back (if prescribed); positioning on the affected side maximizes pressure to the area to prevent bleeding. Options 1, 3, and 4 are correct interventions.

The nurse assigned to 4 clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority? 1. Urine output 240 mL/8 hr 2. Pulse oximetry reading 89% 3. Hemoglobin 12.2 g/dL (122 mmol/L) 4. Potassium level 3.6 mEq/L (3.6 mmol/L)

2. Pulse oximetry reading 89% Priorities are classified as high, intermediate, and low. Setting priorities requires a sound nursing knowledge base. The pulse oximetry is well below normal and indicates the highest priority. Inadequate oxygenation to tissues is life threatening. The hemoglobin level and the potassium level are within normal range, and these are low priorities. The urine output reading is marginal: 240 mL in an 8-hour period would indicate adequate but low urine output; this presents an intermediate priority.

The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? 1. The client who lacks knowledge regarding postoperative home care 2. The client with problems clearing the airway related to abdominal incision pain 3. The client with tissue perfusion alterations related to postoperative venous stasis 4. The client who is at risk for infection related to a history of smoking for 20 years

2. The client with problems clearing the airway related to abdominal incision pain Priority care is focused on the client who has an ineffective airway. Although postoperative home care teaching is essential before discharge, there is no indication that the client is ready for discharge. The client with venous stasis has a circulatory issue related to immobility but no indication of an absence of arterial circulation. The potential for infection as a result of long-term smoking is a risk but not the most immediate concern. All 3 problems are important, but the client in the correct option has an airway concern, which supersedes the other clients' immediate needs.

The nurse has received her client assignment for the day. Which client should the nurse check first? 1. A client experiencing severe pain 2. A client who is hearing voices in his head 3. A client who has just returned from surgery 4. A client who is in 4-point leather restraints

3. A client who has just returned from surgery Priority clients are those who have a problem or potential problem with airway, breathing, or circulation. A client who has just returned from surgery could experience problems with all three. The client experiencing severe pain would be attended to next. Then the nurse would care for the client who is hearing voices in his head, followed by the client who is in 4-point leather restraints.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3. A client who requires urine specimen collections The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by UAPs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

Which client should the emergency department triage nurse classify as emergent? 1. A client with a displaced fracture who is crying 2. A client with a simple laceration and soft tissue injury 3. A client with crushing substernal pain who is short of breath 4. A client with a temperature of 101°F (38.3°C) with a productive cough

3. A client with crushing substernal pain who is short of breath A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experiencing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim experiencing altered level of consciousness

3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? 1. Monitor temperature. 2. Monitor urine output. 3. Monitor respiratory status. 4. Encourage increased fluids.

3. Monitor respiratory status. Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be components of the plan of care, the correct choice identifies the priority nursing action.

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? 1. Prepare the child for tracheotomy. 2. Prepare to administer epinephrine. 3. Prepare the child for a chest radiograph. 4. Assist the health care provider with intubation.

3. Prepare the child for a chest radiograph If epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest radiograph to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway. Epinephrine is not used in the treatment of epiglottitis.

The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Which is important information for the nurse to remember? 1. That an informed consent does not need to be obtained 2. That an informed consent should be obtained from the family 3. That an informed consent needs to be obtained from the client 4. That the health care provider will provide the informed consent

3. That an informed consent needs to be obtained from the client Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client. Therefore, options 1, 2, and 4 are incorrect.

The nurse hears a client calling out for help and finds the client lying on the floor. The nurse performs an assessment and assists the client back to bed. The health care provider is notified of the incident, and the nurse completes an incident report. What should the nurse document on the incident report? 1. The client fell out of bed last night. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client was restless and tried to get up.

3. The client was found lying on the floor. The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only choice that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual data as observed by the nurse.

The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1. A client who has a tympanic temperature of 99.8°F 2. A client who has a regular radial pulse of 96 beats/minute 3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85%

4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is needed to maintain the client's oxygenation status. A tympanic temperature of 99.8°F is mildly elevated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96 beats/minute is elevated, as is the supine resting blood pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than respiratory status.

The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse should intervene if an unlicensed assistive personnel (UAP) is observed taking which action? 1. Obtaining the client's vital signs 2. Assisting the client with repositioning in bed 3. Telling the client that warm sitz baths may be prescribed 4. Insisting that the client ambulate immediately after the procedure

4. Insisting that the client ambulate immediately after the procedure The client who has undergone a cystoscopy with biopsy should not walk alone immediately after the procedure because orthostatic hypotension may occur. Options 1, 2, and 3 are appropriate. Therefore, the nurse would intervene if the UAP is observed insisting that the client ambulate immediately after the procedure.

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse should take which priority action? 1. Send the client to surgery without the consent form being signed. 2. Have the hospital chaplain sign the informed consent immediately. 3. Notify the health care provider (HCP) to obtain a court order for the surgery. 4. Obtain telephone consent from the family member witnessed by 2 authorized individuals.

4. Obtain telephone consent from the family member witnessed by 2 authorized individuals. Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by 2 authorized individuals who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under sedation. In emergencies, the client may be unable to sign and family members may not be available. In this type of situation, the HCP is legally permitted to perform surgery without consent. Options 1 and 2 are not appropriate. In addition, actions that delay treatment in an emergency are not appropriate.

The nurse has received the client assignment for the day. Which client should the nurse care for first? 1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the health care provider because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy. The client who has a mastectomy is expected to have sensations of tightness and pulling.

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 1. The 11-year-old with burns to 10% of both legs 2. The sobbing 10-year-old with an obvious fracture of the forearm 3. The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute 4. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

4. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur Triage systems identify who should be treated first. Rankings are based on immediacy of needs, including immediate threats to life such as airway compromise or hemorrhagic shock. The 12-year-old who is demonstrating confusion is becoming hypoxic because of profound blood loss. The other victims are more stable and could wait.

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used.

Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether the issue involves an ethical dilemma and gathers information that is relevant to the case. Second, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that would allow the nurse to preserve integrity yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action.

When planning care, which client should the nurse assess first? 1. The client with a chest tube for a pneumothorax 2. The client who had a cholecystectomy 2 days earlier 3. The client who is receiving total parenteral nutrition and lipids 4. The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)

1. The client with a chest tube for a pneumothorax The client with a chest tube for a pneumothorax should be assessed first, based on the airway compromise. This client could very well have problems with breathing. A client with total parenteral nutrition and lipids will need a site and rate check. The client who had a cholecystectomy 2 days earlier needs to have the incision checked, and the client on contact isolation for MRSA has to be assessed by the nurse, but these conditions are not life threatening, as an alteration in breathing could be.

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1. Victim with an open fracture of the left lower extremity 2. Victim who is crying hysterically and complaining of pain in the right ankle 3. Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4. Victim with an apparent chest wall defect and asymmetrical chest wall movement

4. Victim with an apparent chest wall defect and asymmetrical chest wall movement The victim in option 4 will continue to have a decline in respiratory status and imminent threat to life unless immediate intervention is instituted. The victims in options 1 and 2 have conditions that can wait to be treated. The victim in option 3 is dead.

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client is resting in bed with the eyes closed. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion. 1. The client is resting in bed with the eyes closed. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor. The incident report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply. 1. "This document is a separate document from my final will." 2. "This document is strictly for indicating if I want to be resuscitated." 3. "I need to have my family sign this document in case my condition worsens." 4. "This document describes the kind of treatment I want depending on how sick I am." 5. "This document tells what I want and gives medical power of attorney to my doctor."

1. "This document is a separate document from my final will." 4. "This document describes the kind of treatment I want depending on how sick I am." An advance directive describes the specific medical treatment that a client wants if he or she is unable to make decisions about care. An advance directive is a separate document from the final will. The family does not need to sign an advance directive. Medical power of attorney is a type of advance directive but requires separate documentation. A do not resuscitate order is a type of advance directive, but an advance directive encompasses additional information. Therefore, options 2, 3, and 5 are incorrect.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1. A client needing a bed bath 2. A client needing to ambulate 3. A client needing packed red blood cells 4. A client requiring assistance with feeding 5. A client needing to have vital signs checked 6. A client needing to use the bedside commode

1. A client needing a bed bath 2. A client needing to ambulate 4. A client requiring assistance with feeding 5. A client needing to have vital signs checked 6. A client needing to use the bedside commode UAPs can perform tasks that are noninvasive. Therefore, options 1, 2, 4, 5, and 6 are tasks that the UAP can perform. The client in option 3 must be cared for by the registered nurse.

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 1. A victim experiencing dyspnea 2. A victim experiencing confusion 3. A victim experiencing tachycardia 4. A victim experiencing intense pain

1. A victim experiencing dyspnea The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.

The nurse discovers a co-worker in the linen closet injecting a medication into the antecubital area. Which most appropriate action should the nurse take? 1. Call the police. 2. Notify security. 3. Call the nursing supervisor. 4. Ignore what was discovered to avoid conflict.

3. Call the nursing supervisor. The Nurse Practice Act requires reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. Option 4 is an inappropriate action and can affect client safety and safety to others.

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. Which term describing this organizational chart should the vice president employ while talking with the employees? 1. Flat 2. Vertical 3. Circular 4. Horizontal

1. Flat Organizational charts are drawings that show how the parts of an organization are linked. In "flat" organizations, authority and responsibility are delegated to the lowest operational level possible. Option 2 is incorrect because a vertical chart indicates a formal line of authority and communications. Traditionally, vertical charts indicate decision making at the upper levels of management. Option 3 indicates a concentric or circular chart, with the chief executive in the center and successive layers of authority. Option 4 refers to a horizontal, or left-to-right, chart that depicts the chief executive at the left, with lower layers of the authority to the right.

The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? 1. "Actual or life-threatening concerns are the priority." 2. "Completing care in a reasonable time frame is the priority." 3. "Time constraints related to the client's needs are the priority." 4. "Obtaining the needed supplies to care for the client is the priority."

1. "Actual or life-threatening concerns are the priority." Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.

The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate should indicate to the nurse that there is a need for further teaching? 1. "I don't think you need to do that." 2. "Tell me about making that decision." 3. "I would like to be sure I understood." 4. "When did you first notice you felt that way?"

1. "I don't think you need to do that." The correct option is very clearly a judgmental response, as it specifically casts judgment on an action. The remaining options seek to explore with the client as opposed to commenting on or giving advice.

The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

3. Democratic Democratic styles empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Situational leadership uses a style that depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision.

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1. "Cushing's syndrome is caused by excessive amounts of cortisol." 2. "Cushing's syndrome is caused by decreased amounts of aldosterone." 3. "Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4. "Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

1. "Cushing's syndrome is caused by excessive amounts of cortisol." Cushing's syndrome is a condition caused by excessive amounts of cortisol. Options 2, 3, and 4 are inaccurate descriptions of this disorder.

A client refuses to take a medication. Which is the most therapeutic response by the nurse? 1. "I'll come back later to see if you have changed your mind." 2. "You don't have to take the medication if you don't want to." 3. "This medication is going to help you get better, so why don't you go ahead and take it?" 4. "Do you want me to call your health care provider (HCP) and tell him you won't take your medication?"

2. "You don't have to take the medication if you don't want to." The client has the right to refuse medications or any other aspect of therapy. Therefore, the correct option is the therapeutic response. Options 3 and 4 are degrading and scold the client. Although option 1 is a possible choice, it isn't the best or therapeutic one.

A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? 1. "They are developed based on appropriate standards of care." 2. "They are nursing care plans and use the steps of the nursing process." 3. "They are developed through the collaborative efforts of members of the health care team." 4. "They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."

2. "They are nursing care plans and use the steps of the nursing process." Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. All other options appropriately describe the use of a critical path.

The nurse determines that which client has the highest priority needs? 1. The client who has a rectal temperature of 99.8°F 2. The client who has a blood pressure of 110/70 mm Hg 3. The client who has an oxygen saturation percentage of 95% 4. The client who has an irregular apical pulse of 120 beats per minute

4. The client who has an irregular apical pulse of 120 beats per minute An elevated and irregular pulse rate requires immediate evaluation. A rectal temperature of 99.8°F (37.7°C) is also normal. The blood pressure reading of 110/70 mm Hg does not present a concern unless the client is symptomatic. An oxygen saturation percentage of 95% is a normal oxygen saturation reading.

The nurse gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the health care provider to report the occurrence. Which action should the nurse manager anticipate will take place next? 1. The incident will be reported to the board of nursing. 2. The incident will be documented in the personnel file. 3. The error will result in suspension and be written in the annual performance appraisal. 4. The incident report will be used to review quality of care and determine potential risks.

4. The incident report will be used to review quality of care and determine potential risks. Documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result is maintained by the institution or agency and allows the nurse and administration to review quality of care and determine any potential risks. Based on the information provided in the question, the nurse's error will not result in suspension and be written in the annual performance appraisal, nor will it be documented in the personnel file. The error and the situation presented in the question are not reasons for notifying the board of nursing.

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client requiring dressing changes 2. A client requiring frequent temperature measurements 3. A client on a bowel management program requiring rectal suppositories and a daily enema 4. A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

2. A client requiring frequent temperature measurements Assignment of tasks to the UAP needs to be made based on job description, level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. The client described in the correct option has needs that can be met by a UAP.

The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? 1. Put on gloves. 2. Evaluate the client's visual acuity. 3. Place the client in a supine position. 4. Place a strip of pH paper in the lower sac of the client's affected eye.

2. Evaluate the client's visual acuity. Before performing an ocular irrigation on a client who had an episode of splashing in the eye, the nurse must first evaluate the client's visual acuity. All of the other options can then be performed.

The community health nurse is working with disaster relief personnel after a hurricane that ruined many homes in the local community. The nurse is working to find housing for the survivors and is organizing counseling services. Which prevention level do the nurse's actions represent? 1. Primary 2. Secondary 3. Tertiary 4. Quaternary

3. Tertiary Tertiary prevention involves reduction of the amount and degree of disability, injury, or damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. There is no known quaternary care prevention level.

Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? 1. Libel 2. Slander 3. Assault 4. Negligence

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

The nurse should instruct the unlicensed assistive personnel (UAP) to avoid the use of a straight razor for which client? 1. The postoperative client 2. The client taking warfarin 3. The client with an infection 4. The client taking acetaminophen

2. The client taking warfarin Warfarin is an anticoagulant, which places the client at risk for bleeding. Use of a straight razor increases the risk of abrasion and bleeding because of the client's ineffective clotting capability. Postoperative status, infection, and taking acetaminophen are not affected by the choice of shaving tools.

A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1. A client is performing colostomy irrigations. 2. The client with a leg ulcer is demonstrating signs of wound healing. 3. A postoperative client is discharged home 1 day earlier than expected. 4. The client with diabetes mellitus is administering insulin injections appropriately.

3. A postoperative client is discharged home 1 day earlier than expected. Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The correct option is the only one that identifies a positive variance. Options 1, 2, and 4 demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? 1. Primary level of prevention 2. Secondary level of prevention 3. Tertiary level of prevention 4. Quaternary level of prevention

3. Tertiary level of prevention Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery. In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse? 1. Manager 2. Educator 3. Advocate 4. Caregiver

4. Caregiver The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights.

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? 1. "As the manager, do you maintain control and make all decisions?" 2. "As the manager, do you assume a passive, nondirective approach?" 3. "As the manager, do you facilitate decision making within the group?" 4. "As the manager, do you change style according to the needs of the group?"

2. "As the manager, do you assume a passive, nondirective approach?" A laissez-faire leader assumes a passive, nondirective approach. Option 1 describes an autocratic leader; this type of leader would make the decisions. Option 3 describes a democratic leader. This type of leader is a "talk with the members" type of leader who gains input and facilitates decision making by the group. Option 4 describes a situational leader; this is seen when a manager indicates that in some situations, the manager decides, but in other situations, the staff nurses decide.

The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. Drag the text in the left column to the correct order in the right column. 1. Reposition the client. 2. Stop the oxytocin infusion. 3. Perform a vaginal examination. 4. Check the client's blood pressure. 5. Administer oxygen by face mask at 8 to 10 L/min. 6. Administer medication as prescribed to reduce uterine activity.

If uterine hypertonicity occurs, the nurse would immediately intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the no additive solution, position the client in a side-lying position, and administer oxygen by face mask at 8 to 10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal examination to check for a prolapsed cord. The nurse would check maternal blood pressure for the presence of hypertension or hypotension. The nurse stays with the client and contacts the health care provider (HCP) as soon as possible (or asks another nurse to contact the HCP) and then implements the HCP's prescriptions, including the administration of medications to reduce uterine activity.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. Drag the text in the left column to the correct order in the right column. 1. Hang the bag of blood. 2. Obtain the unit of blood from the blood bank. 3. Ensure that an informed consent has been signed. 4. Insert an 18- or 19-gauge intravenous catheter into the client. 5. Verify the health care provider's (HCP's) prescription for the blood transfusion. 6. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity.

The nurse would first verify the HCP's prescription for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions, and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, 2 registered nurses or 1 registered nurse and 1 licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion.

The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic The autocratic style of leadership is task oriented and directive. Situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and provides an opportunity to grow professionally. The laissez-faire style allows staff to work without assistance, direction, or supervision.

The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 4. Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr 5. Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92% 6. Client with white blood cell count of 2200 mm3 (2.2 × 109/L), temperature of 102°F (38.9°C), and blood pressure of 90/40 mm Hg

1. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma Clients in options 1, 2, and 3 demonstrate no evidence of instability and can be discharged safely. The client in option 4 is demonstrating impaired gas exchange and fluid overload and requires oxygen. The client in option 5 requires intravenous fluid replacement because of vomiting. Without fluid replacement, the client is at risk for dehydration and electrolyte imbalances. The client in option 6 demonstrates signs of infection and hemodynamic instability and is at risk for developing septic shock. These clients should not be discharged at this time.

While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client? 1. Talking about clients in public places is a violation of the client's confidentiality. 2. The client's rights to confidentiality do not apply to the break time of employees. 3. It is acceptable for the nurses to talk about a client because they are on the same treatment team. 4. The nurses taking care of the client should not share information with each other that the client has told them separately.

1. Talking about clients in public places is a violation of the client's confidentiality. Although it is acceptable for the nurses on the same treatment team for a client to discuss his or her treatment, it is not appropriate to do so in the cafeteria or any other place, particularly when others could potentially hear this conversation. The nurse cannot violate confidentiality during the professional's personal time. There is not a time during which it is acceptable to violate confidentiality except in the case of a life-or-death emergency.

The registered nurse (RN) is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the RN to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. Which statement made by the nurse is the most appropriate? 1. "Case management is an important concept, but it doesn't promote appropriate use of personnel." 2. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." 3. "Case management saves money for the institution because clients with similar problems are all treated in the same manner." 4. "Case management requires an experienced nurse because it represents a primary health prevention focus and is managed by a single nurse."

2. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." Case management represents an interdisciplinary health care delivery system that promotes appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcomes of client care. The remaining options are inaccurate statements regarding case management.

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is schedu

2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 1. A client with dyspnea 2. A client experiencing sinus rhythm 3. A client receiving oral anticoagulants 4. A client with chronic atrial fibrillation 5. A client experiencing third-degree heart block 6. A client who has not voided since before surgery

2. A client experiencing sinus rhythm 3. A client receiving oral anticoagulants 4. A client with chronic atrial fibrillation Clients should be medically stable if discharged and should be able to manage their condition at home independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the medication and is provided with education about the medication. The client in option 4 can be discharged because the client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client experiencing third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be discharged after surgery until they have voided.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. A client with chest pain 2. A client with a Holter monitor 3. A client receiving oral antibiotics 4. A client experiencing sinus rhythm 5. A client newly diagnosed with atrial fibrillation 6. A client experiencing third-degree heart block who requires a pacemaker

2. A client with a Holter monitor 3. A client receiving oral antibiotics 4. A client experiencing sinus rhythm Clients should be medically stable if discharged and should be able to manage their condition at home. A client experiencing chest pain could be having a myocardial infarction and needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication and monitoring to stabilize the condition. A client in third-degree heart block is considered unstable, especially if the client needs a pacemaker.

The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised? 1. Autocratic 2. Democratic 3. Situational 4. Laissez-faire

2. Democratic Democratic leadership is defined as participative, with a focus on the belief that all members of the group have input into the decision-making process. This leader acts as a resource and facilitator. Autocratic leadership dominates the group, with maintenance of strong control over the group. Situational leadership is based on the current events of the day. Laissez-faire leaders assume a passive approach, with the decision making left to the group.

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? 1. Administer 1 more enema. 2. Stop administering the enemas. 3. Continue to administer enemas until the solution is clear. 4. Wait for 1 hour and then continue administering the enemas.

2. Stop administering the enemas. Client preparation for a barium enema may include the administration of enemas before the test. If administering enemas until clear is prescribed on the morning of the test, enemas should be administered no more than 3 times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances.

The nurse has received her client assignment for the day. Which client should the nurse care for first? 1. The 43-year-old client admitted for observation who has absence of bowel sounds 2. The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath 3. The 49-year-old client who is scheduled for surgery within the next 2 hours and will undergo a hysterectomy 4. The 12-hour postoperative client who has undergone pneumonectomy and is completing a blood transfusion

2. The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath Airway, breathing, and circulation take precedence, in that order of priority. The client with shortness of breath takes priority over the other clients. The clients in options 3 and 4 would be cared for next, followed by assessment of the client who was admitted for observation.

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. The client with heart failure (HF) who has bilateral rhonchi 2. The client who 24 hours earlier gave birth to her second child by caesarean delivery 3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 4. The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C) 5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

2. The client who 24 hours earlier gave birth to her second child by caesarean delivery 3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation The client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients could be cared for at home with the help of a home health care nurse.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A middle-aged man with 1 foot trapped under the wreckage 2. A crying teenager who is holding pressure on an arm laceration 3. A young woman who appears dazed and confused and is shivering 4. A screaming middle-aged woman looking frantically for her husband

3. A young woman who appears dazed and confused and is shivering The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? 1. A client who requires teaching about an insulin pump 2. Completing an admission assessment on a newly admitted client 3. Administration of a new oral medication to a client with Alzheimer's disease 4. An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

3. Administration of a new oral medication to a client with Alzheimer's disease Oral medication administration is within the scope of practice for an LPN. Teaching is the responsibility of the registered nurse (RN). Assessments are also done by the RN. The LPN's scope of practice is restricted to data collection.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open massive head injury in deep coma

3. Bright red bleeding from a neck wound The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first? 1. The 80-year-old client with metastatic cancer to the brain who is confused and on 1-to-1 observation with a sitter in the room 2. The 55-year-old client with breast cancer who is scheduled for a computed tomographic (CT) scan of the brain at 0900 to rule out metastasis 3. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon 4. The 70-year-old client who was admitted at 0500 with the medical diagnosis of pneumonia and a temperature of 102.6°F (39.2°C). This client received acetaminophen at 0600 and now has a temperature of 100.0°F (37.8°C).

3. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon The nurse would plan to first see the client who is receiving chemotherapy for the first time. This is the highest priority because of the potential side and adverse effects of the medication and the fact that this is the first dose the client has received. The confused client with a sitter is safe. The client who is scheduled for a CT scan can wait because her scheduled test is not until 0900. The client with fever is stable for now.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response by the nurse is most appropriate? 1. "I will need to sign as a witness to your signature." 2. "It is your responsibility to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor for assistance regarding your request."

4. "I will call the nursing supervisor for assistance regarding your request." Living wills are required to be in writing and signed by the client. The client's signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including the nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response? 1. "She's okay; she just gets confused at night." 2. "I'm not allowed to say anything to you about her." 3. "She has Alzheimer's disease and gets very upset because she is not home." 4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients." To keep client information confidential, the nurse should not discuss any aspects of a client's care with other clients or with staff who are not involved in the client's care. Simply saying "I'm not allowed" is correct, but abrupt. The correct answer acknowledges the client's concern yet preserves the other client's privacy. Relaying any information about the other client would be a violation of that client's privacy and would not be in compliance with the Health Insurance Portability and Accountability Act.

An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? 1. A child with a bleeding laceration 2. A 54-year-old woman with a fractured wrist 3. A 67-year-old woman with first-degree burns on her hands and arms 4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis

4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis Triage is the decision-making process used to determine client treatment priorities based on the severity of injury and priority for treatment. Depending on the acuteness of the client's condition, a priority rating based on the severity of illness or injury is assigned, after which the client proceeds with emergency department registration or is taken into the treatment area for immediate care. Airway is always a priority, and a client who complains of chest pain is assigned an immediate care priority rating. In the case of the child with a bleeding laceration (option 1), additional pressure can be applied to control the bleeding. The clients in options 2 and 3 do not have injuries that are life threatening, and these clients can wait to be treated.

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client scheduled to receive a blood transfusion 2. A client with bladder cancer who will be receiving chemotherapy 3. A client newly diagnosed with diabetes mellitus scheduled for discharge 4. A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

4. A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client on bed rest who requires ROM exercises. The UAP is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require assessment skills that only a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and coordination of necessary home care services.

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? 1. A primigravida client in the active stage of labor 2. A multigravida client who was admitted for induction of labor 3. A client who is not contracting but has suspected premature rupture of the membranes 4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor Magnesium sulfate is a central nervous system depressant, and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/minute), severe hypotension, and absent deep tendon reflexes. This client should be seen before the clients in all other options because their conditions are stable.

The nurse has received her client assignment for the day. Which client should the nurse care for first? 1. A client requiring a preoperative intravenous antibiotic 2. A client with emphysema who has shortness of breath after just ambulating 3. A client with serous drainage on an incisional spinal wound post laminectomy 4. A client with postoperative pain reported at 7 out of 10, with 10 being the worst

4. A client with postoperative pain reported at 7 out of 10, with 10 being the worst In this situation, the client with the pain reported at 7 out of 10 should be cared for first. The pain will intensify and be harder to manage if treatment is delayed. Caring for the client in pain may delay administration of the preoperative antibiotic but does not jeopardize safe and effective care. Shortness of breath is expected in a client with emphysema after ambulation and therefore is not the priority. Serous drainage is expected from a surgical incision and does not indicate an emergency.

The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who should the nurse manager contact next? 1. Assigned nurse, to increase client care interventions 2. Family, to determine what is wrong and provide suggestions 3. Health care provider (HCP) and assigned nurse, to determine measures to discharge the client 4. Case manager, the determine whether the predicted residence had been p

4. Case manager, to determine whether the predicted variance has been negotiated with the health insurer Option 4 is correct because the nurse manager of the unit is accountable for cost recovery. In this situation, documentation is complete; however, each client's progress along the critical path can vary. Option 1 is incorrect because there is no indication that the care is ineffective. There is no need to contact the HCP and assigned nurse (option 3) or the family (option 2) because the subject is cost recovery. The nurse manager works to be certain that the costs incurred will be negotiated with the insurer at the time that the variance is detected and that the hospital is paid for the costs of providing care longer than the period defined by the critical path.

A homeless client comes to the emergency department complaining of severe pain in the toes of both feet. On assessment, it is found that all of the toes are black in color and that amputation is necessary. The client refuses the surgery and insists on returning to street living. Which describes the next appropriate action to take? 1. Obtain a court order for the surgical procedure. 2. Restrain the client and transport to the operating room for surgery. 3. Call the police to identify the client and to arrest the client until permission for surgery is granted. 4. Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings.

4. Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings. In general, there are only 2 situations in which the informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. In this situation, informed consent is necessary if the client is mentally competent. Option 1 is unnecessary and not the next appropriate action. Restraining the client and having the client arrested violates client rights. The next appropriate action to take is to explore and determine the reasons why the client is refusing surgery and to allow the client an opportunity to express any concerns.

The nurse has made an error in documenting an assessment finding in the client's record. What action should the nurse take to correct the error? 1. Write the late entry in the client's record. 2. Erase the error and rewrite the correct data. 3. Use white correction fluid or tape to cover the error and write in the correct assessment findings. 4. Draw a line through the error, initial and date the line, and then provide the correct information.

4. Draw a line through the error, initial and date the line, and then provide the correct information. If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then providing the correct information. Erasing data from the client's record and using white correction fluid or tape are prohibited. A late entry is used to document additional information not remembered at the initial time of documentation. Procedures for correcting an error via the use of electronic documentation may be different, and the nurse should follow agency guidelines.

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. Take the client's vital signs. 1 Retest the blood glucose level. 2 Check the client's blood glucose level. 3 Give the client ½ cup (118 mL) of fruit juice to drink. 4 Give the client a small snack of carbohydrate and protein. 5 Document the client's complaints, actions taken, and outcome.

The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first will check the client's blood glucose level to verify that the client is experiencing hypoglycemia. Once this is verified, the nurse will give the client 10 to 15 g of carbohydrates, such as a ½ cup (118 mL) of fruit juice. The nurse will retest the blood glucose level after 15 minutes. While waiting the 15 minutes, the nurse will check the client's vital signs. The nurse will give the client another 10- to 15-g carbohydrate food item if the client's symptoms do not resolve. Otherwise, the nurse will provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than 1 hour away from the time of the occurrence. After treatment and resolution of the hypoglycemic event, the nurse will document the occurrence, actions taken, and outcome.

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used. Drag the text in the left column to the correct order in the right column. 1. A client requiring supervision of a dressing change 2. A client being visited by the home health aide at 1030 3. A client requiring an admission assessment to home health care 4. The first dressing change for a client requiring twice-daily dressing changes 5. A client with diabetes mellitus who needs a fasting blood glucose level drawn 6. The second dressing change for a client requiring twice-daily dressing changes

The nurse would plan to visit the client with diabetes mellitus first and draw the fasting blood glucose level because this client needs to remain NPO (nothing by mouth) until the blood is drawn. This client also would be unable to take any medication, such as insulin, until the blood is drawn. The nurse would plan to see the client requiring twice-daily dressing changes next because the dressing changes should be spaced as far apart as possible. The nurse then would plan to see the client being visited by the home health aide and provide instructions and directions to the home health aide regarding care of the client. The nurse then would visit the client requiring supervision of the dressing change and would perform the admission assessment next because that may take more time than the other clients. The nurse then would return to the client requiring the second twice-daily dressing change; dressing changes should be spaced as far apart as possible.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? 1. Place the client in a side-lying position. 2. Initiate wound care protocol for standardized ulcer care. 3. Meet with the wound specialist to identify measures to improve healing. 4. Determine which treatments would best meet the healing needs of the client.

1. Place the client in a side-lying position. The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2. Performing strict hand-washing technique 3. Wearing gloves and a gown only when giving direct care to the client 4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3. Wearing gloves and a gown only when giving direct care to the client In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance during the change process. Which primary technique should the nurse use in implementing this change? 1. Introduce the change gradually. 2. Use coercion to implement the change. 3. Manipulate the participants in the change process. 4. Confront the individuals involved in the change process.

1. Introduce the change gradually. The primary technique that can be used to handle resistance to change during the change process is to introduce the change gradually. Coercion can be used to decrease resistance to change, but it is not always a successful technique for managing resistance. Manipulation usually involves a covert action, such as leaving out pieces of vital information that the participants might receive negatively. It is not the best method of implementing a change. Confrontation is an important strategy used when resistance occurs.

The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? 1. Organize, manage, and balance health care services needed for the client. 2. Report daily to all members of the client's health care team to advise them of the plans. 3. Plan weekly meetings with all persons involved in the care of this client to assess status. 4. Conduct daily teaching sessions for the client and significant others about the case management process.

1. Organize, manage, and balance health care services needed for the client. The role of the case manager is to organize, manage, and balance health care services needed for the client. Although options 2, 3, and 4 may be aspects of the role of the case manager, the correct option identifies the overall role.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. 1. Provide monetary relief. 2. Provide crisis counseling. 3. Identify and train personnel. 4. Issue presidential declarations. 5. Deploy National Guard troops. 6. Handle inquiries from families.

2. Provide crisis counseling. 3. Identify and train personnel. 6. Handle inquiries from families. In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.

Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. 1. Assessment 2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration 6. Intravenous push medication administration

2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration In general, an LPN can perform the tasks that an unlicensed assistive personnel can perform (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, some piggyback medications). Assessment and administration of intravenous medications are responsibilities of the RN and outside of the scope of practice of the LPN.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client." 2. "A client's rights are guaranteed by both state and federal laws." 3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4. "Regardless of the client's condition, all nurses have the duty to value client rights."

3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true that autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the unlicensed assistive personnel (UAP) to implement which action when caring for the client? 1. Ambulate the client frequently. 2. Encourage a diet that is high in protein. 3. Remove the water pitcher from the bedside. 4. Monitor the client's temperature every 2 hours.

3. Remove the water pitcher from the bedside. The client with acute glomerulonephritis commonly experiences an excess of fluid volume and fatigue. Interventions include fluid restriction and monitoring weight, intake, and output. The diet is high in calories but low in protein. The client is placed on bed rest, or at least encouraged to rest, because there is a direct correlation between proteinuria and hematuria and increased activity levels. It is unnecessary to monitor the temperature as frequently as every 2 hours.

A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which action by the LPN requires follow-up by the RN? 1. The LPN keeps the client's knee at the hinged joint of the machine. 2. The LPN assesses the client for pressure areas at the knee and the groin. 3. The LPN places the client's knee in a slightly externally rotated position. 4. The LPN checks the degree of extension and flexion and the speed of the CPM machine according to the health care provider's (HCP's) prescriptions.

3. The LPN places the client's knee in a slightly externally rotated position. In the use of a CPM machine, the leg should be kept in a neutral position and not rotated either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse should monitor for pressure areas at the knee and the groin and should follow the HCP's prescriptions and institutional protocol regarding extension and flexion and the speed of the CPM machine.

The nurse is planning client assignments for the day. Which clients can be safely assigned to unlicensed assistive personnel (UAPs)? Select all that apply. 1. Client who is receiving chemotherapy and is in isolation 2. Client with anemia who is receiving a second unit of blood and needs assessment of vital signs 3. Client newly diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy 4. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding 6. Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment

4. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding The scope of practice of UAPs includes measurement of vital signs and assistance with feeding, bathing, and dressing. Clients who need assessment, are receiving chemotherapy, are receiving blood, or require education need the more advanced skills of a licensed nurse.

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her yourself." 3. "Only because you're worried about a friend, I'll tell you that she is improving." 4. "Being her friend, you know she is having a difficult time and deserves her privacy."

1. "I cannot discuss any client situation with you." The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Inspecting skin surfaces 2. Observing the client's behavior 3. Measuring the client's height and weight 4. Assessing the client's general appearance 5. Monitoring oral intake and urinary output

3. Measuring the client's height and weight 5. Monitoring oral intake and urinary output The general survey is a review of the client's main health problems and includes assessment of vital signs, height and weight, general behavior, and appearance. The nurse can delegate some aspects, such as measuring height and weight and monitoring intake and output, to UAPs, but the nurse is responsible for performing the general survey, including assessment of general appearance, behavior, and skin.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended.

The registered nurse (RN) is planning her client assignments for the day. She has a licensed practical nurse and an unlicensed assistive personnel (UAP) on her team. Which task should the RN delegate to the UAP? 1. Empty a client's urinary catheter bag. 2. Instruct a client on his new diabetic diet. 3. Teach a client how to check her blood glucose. 4. Evaluate a newly admitted client's home medications.

1. Empty a client's urinary catheter bag. The nurse must delegate tasks according to the educational level of staff members. Unlicensed personnel such as a UAP can perform tasks that are noninvasive, such as emptying a urinary catheter bag. Additionally, UAPs are not trained to teach or evaluate. Only an RN can teach, evaluate, and instruct.

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the unlicensed assistive personnel (UAP)? 1. Orient the client to the hospital surroundings. 2. Instruct the client on how to apply the eye drops. 3. Listen to the client express his frustration or loss. 4. Review hand washing and hygiene practices with the client.

1. Orient the client to the hospital surroundings. Orienting the client to the hospital room and surroundings is within the scope of the UAP's responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to UAPs.

The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit? 1. The Good Samaritan law will protect the nurse. 2. The Good Samaritan law will not protect the nurse. 3. The Good Samaritan law protects laypersons but not professional health care providers (HCPs). 4. The Good Samaritan law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided.

1. The Good Samaritan law will protect the nurse. A Good Samaritan law is passed by a state legislature to encourage nurses and other HCPs to provide care to a person when an accident, emergency, or injury occurs without fear of being sued for the care provided. Its protection lies in the inability to sue the nurse or other HCP for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the HCP's care. Called immunity from suit, this protection usually applies only if all conditions of the law are met, such as that the HCP received no compensation for the care provided and the care given was not willfully and wantonly negligent.

The nurse suspects that a client is not fully aware of the implications of a procedure and the client is about to sign an informed consent. What action would be most appropriate for the nurse to take? 1. Ask a family member to sign the consent because the client seems unsure at this time. 2. Tell the client that he can ask the health care provider (HCP) for more details when he gets to the operating room. 3. Ask the client if the HCP explained the procedure before obtaining the signature. 4. Inform the HCP that the client does not appear to fully understand the procedure and withhold obtaining the signature.

4. Inform the HCP that the client does not appear to fully understand the procedure and withhold obtaining the signature. The only safe action is to inform the HCP that the client does not appear to fully understand the procedure and withhold obtaining the signature. Asking the client if the HCP explained the procedure is insufficient because the client may give a "yes" or "no" answer to the question and may want to sign the consent without adequate information. It is never appropriate to defer the signature to a family member unless that person has legal authorization to sign for the client. It is unsafe to tell the client that he can ask the HCP for more details when he gets to the operating room because he may have received sedating medications.

The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor and I want to check on her." The nurse should make which most appropriate response? 1. "I'm sorry, I cannot tell you." 2. "The condition of the client in room 432 is good." 3. "You can get the information from the client's chart." 4. "I don't think you should be asking me that question."

1. "I'm sorry, I cannot tell you." The nurse has a legal obligation to protect the client's right to confidentiality and legally cannot share any information about the client with a neighbor. In addition, it is only on a need-to-know basis that client information should be shared with other health care personnel who are directly involved in the client's care. Option 1 is factual and honest. Options 2 and 3 inappropriately provide client information. Although option 4 is correct, it is an inappropriate statement and is challenging.

A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? 1. Using a Z-track method for injection 2. Massaging the injection site after injection 3. Preparing an air lock when drawing up the medication 4. Changing the needle after drawing up the dose and before injection

2. Massaging the injection site after injection The site should not be massaged after injection because massaging could cause staining of the skin. Z-track technique and an air lock both should be used. Proper technique for administering iron by the IM route includes changing the needle after drawing up the medication and before giving it. The medication should be given in the upper outer quadrant of the buttock, not in an exposed area such as the arms or thighs.

The nurse is planning the client assignments for a group of clients and has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? 1. A client with stable heart failure who has early-stage Alzheimer's disease 2. A client who is scheduled for an electrocardiogram and a chest x-ray examination 3. A client who was treated for dehydration, is weak, and needs assistance with bathing 4. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion

4. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion The nurse would most appropriately assign the client with emphysema to the LPN. This client has an airway problem and has the highest priority needs among the clients presented in the options. The clients described in options 1, 2, and 3 can appropriately be cared for by the UAP.

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply. 1. Respect assumptions. 2. Monitor language and tone. 3. Adopt a "need-to-know" policy. 4. Be alert to the presence of gossip. 5. Try to limit the use of obscene language. 6. Hold yourself and one another accountable.

2. Monitor language and tone. 3. Adopt a "need-to-know" policy. 4. Be alert to the presence of gossip. 6. Hold yourself and one another accountable. Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a "need-to-know" policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. Change-of-shift report is given from one caregiver to another caregiver who is taking on responsibility for the client's care to ensure continuity of care.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1. Actual or life-threatening concerns 2. Completing care in a reasonable time frame 3. Time constraints related to the client's needs 4. Obtaining needed supplies to care for the client

1. Actual or life-threatening concerns Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.

A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has been losing weight for 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins to cry and tries to eat more. Based on the nurse's actions, the nurse may be accused of which legal tort? 1. Assault 2. Battery 3. Slander 4. Invasion of privacy

1. Assault Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will occur as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the HCP can be contacted. 4. Administer the recommended dose until the HCP can be located.

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

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1. A confused older client who requires feeding 2. A client who requires turning every 2 hours 3. A client admitted with dehydration who is on strict intake and output 4. A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 5. A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift 6. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

1. A confused older client who requires feeding 2. A client who requires turning every 2 hours 3. A client admitted with dehydration who is on strict intake and output 6. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day Activities such as turning, ambulation, maintenance of intake and output, and feeding can be delegated to the UAP. Therefore, clients 1, 2, 3, and 6 can be assigned to the UAP. The clients in options 4 and 5 are or have demonstrated recent instability and should be assigned to the registered nurse for comprehensive assessment.

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.