Coordinated Care
A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse proceed?
Verify placement of the tube.
A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?
Voice her concerns about continuity of care with the charge nurse.
A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication?
Wait for a short time and then attempt to administer the medication
A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority?
a child who develops a fever during a blood transfusion
The nurse receives a call from the laboratory with lab values. Which lab value represents the highest priority for the nurse?
calcium, total 32 mg/dL (8 mmol/L)
A client undergoes rhinoplasty to repair a nasal fracture. Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with bright-red blood. Which is the best action for the licensed practical nurse (LPN) to take?
check the pharynx with a penlight for bleeding, and confer with the registered nurse (RN)
The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?
communication barriers between the mother and staff
The nurse is caring for a client with cardiomyopathy. Which diagnosis should the nurse make a priority to guide this client's care?
decreased cardiac output related to reduced myocardial contractility
The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions?
delegation
A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality?
determining that the client has authorized release of the information
A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?
establish a therapeutic relationship with the client
A client is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes?
including the client in developing a care plan that works toward meeting discharge goals
A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?
increasing fluid intake to 3 L/day
In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values?
integrity
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes
limiting abbreviations to those approved for use by the institution
A nurse is caring for a client with an acute head injury and is ready to begin rehabilitation. When transferring the client from the bed to a chair, what should the nurse do to ensure client safety?
lock the brakes on the bed
Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:
making sure the parents are well informed about their infant's condition and that they've made an informed decision.
When caring for a child with sickle cell anemia in vaso-occlusive crisis, what does the nurse identify as the priority nursing intervention?
manage pain
The nurse is making assignments for the day. Which of the following tasks can be safely assigned to unlicensed assistive personnel (UAP)?
measuring the intake of a client with multiple sclerosis
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?
metabolic acidosis
Which guidelines define and regulate what the nurse may and may not do as a professional?
nurse practice act
During the first few days of recovery from ostomy surgery for ulcerative colitis, what should be the priority of client care?
ostomy care
During an admission history a copy of the living will was provided by the client. The nurse's responsibility at this time is to:
place the document on the client's chart and communicate the information to the health care team.
The parents of a 6-month-old infant diagnosed with a terminal brain tumor have chosen palliative care for their child. What is the priority nursing intervention for this infant?
providing pain management, comfort measures, and support for the parents
The nurse is providing care to a newly admitted client with a mental health disorder. Which of these actions by the nurse violates the client's privacy?
putting the client's name outside of the client's room
A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care?
referral for bereavement counseling
The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:
self-awareness and understanding.
The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)?
sternal pain
A nurse is caring for clients in a subacute unit. Which client care takes priority?
suctioning a tracheostomy client with oxygen saturation of 90%
The nurse is assigned to care for a postoperative client who has diabetes mellitus. During data collection, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
suggest referral to a sex counselor or other appropriate professional.
Which client requires further data collection by the licensed practical nurse (LPN)?
the client who is restless
Professional regulations and laws that govern nursing practice are in place for what reason?
to protect the safety of the public
A nurse is caring for a client on a mental health unit and receives a call asking to know if the client is admitted on that unit. What should the nurse do?
verify the identity of the caller
The nurse is administering medications to a client who has a gastrostomy tube (G-tube). The nurse reads the order for aspirin PO and crushes the aspirin and administers through the G-tube. What medication error did the nurse commit?
wrong route
A 15-year-old comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that the parents might be notified of the test results. Which response by the nurse is most appropriate?
"HIV testing is confidential; after we get the test results, we will discuss your options with you only."
When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition?
"I realize that treatment for diabetes insipidus is lifelong."
A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse?
"I will call the physician with this information."
Which statement by a client demonstrates to the nurse that the client understands the best time to perform a self-breast exam?
"I'll examine my breasts a week after my menstrual period starts."
Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond?
"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."
The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate?
"It's contraindicated because it promotes bleeding tendencies."
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce?
"Monitor your temperature for signs of infection."
A client diagnosed with cancer tells the nurse about wanting to stop treatment and die at home. The healthcare team suggests another round of chemotherapy. What statement by the nurse to the healthcare team best reflects client advocacy?
"The client has expressed not wanting to pursue additional treatment."
A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate?
"The client is infectious 1-2 days before the rash appears and until the blisters are crusted."
A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best?
"The rehabilitation staff can evaluate your progress and help you recover without risking injury."
A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply.
-"I am not able to provide that information." -"Client privacy is part of the hospital code of conduct."
A nurse is working on a medical unit at a unionized hospital that has insufficient nurses and staff to provide competent care to the clients. What should the nurse do? Select all that apply.
-Accept the assignment and make a written protest to the administration. -Complete an unsafe staffing form and provide care as safely as possible.
An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.
-Provide explanations and support to the client. -Attend to the client's physical needs. -Report any signs of abuse to appropriate agencies.
A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply.
-Use polite language while answering questions. -Be prepared to answer questions about the case during the trial.
The nurse completes an incident report after administering an incorrect medication dose to a client. What is the best reason for the nurse to complete an incident report? Select all that apply.
-to identify a situation that is not normal -to investigate and determine the cause
A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN?
9-year-old child receiving subcutaneous insulin for diabetes mellitus
A client has been admitted to the hospital for treatment of kidney stones. The client asks the nurse where the Atkins diet items are on the menu. What is the nurse's understanding of the diagnosis and diet?
A diet high in protein may strain the kidney function.
Which client situation requires the nurse to file an incident report?
A family member who is visiting a client was found on the floor in the client's room.
The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?
A stable 6-month-old infant with pneumonia
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
Acute pain related to biliary spasms
A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation?
Ask for a private meeting to explore the charge nurse's concerns in detail.
A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority?
Ask the client when she last changed her perineal pad.
A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care?
Ask the clinic case manager to speak with the client.
A client who underwent surgery 1 day ago is concerned about worsening incisional pain and isn't scheduled to receive pain medication for 2 hours. Which action by the nurse is most appropriate?
Assess the incision and then notify the charge nurse of the client's worsening pain.
A client with end-stage pulmonary hypertension tells his physician that he doesn't want any heroic measures should his heart stop and that he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is a nurse upholding by supporting the client's decision?
Autonomy
Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client's best interest?
Call a family conference and ask social services for assistance.
A client who has experienced a stroke is unable to move without help. Which intervention should the nurse perform to reduce this client's risk for developing a common complication of immobility?
Change the client's position every 1 to 2 hours.
A client with skeletal fracture to the right leg reports severe right leg pain. Which action should the nurse take first?
Check the client's alignment in bed.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services.
A client with self-inflected wrist lacerations was stabilized in the emergency department and then transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. After initiating antidepressant therapy, the client is now exhibiting an increase in energy levels. What nursing intervention is most appropriate?
Continue suicide precautions.
A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care?
Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session.
A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client?
Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin
A nurse observes a second nurse documenting a peripheral blood glucose level that the second nurse did not actually collect from a client with diabetes. What is the priority action by the nurse observing this situation?
Discuss the observation with the other nurse.
A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond?
Discuss this to define the relationship.
A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client?
Encourage the client to ambulate.
After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's child returns to the hospital 6 hours later to find that the client remains on a stretcher in the emergency department hallway. The child begins to shout "I will not allow my insurance to pay for your failure to provide care." What is the best action for the nurse to take in this situation?
Ensure the comfort and security of the client and meet privately with the family member.
A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care?
Good Samaritan laws are designed to protect the caregiver in emergency situations.
An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination?
Have a female health care worker present.
A licensed practical nurse (LPN) who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short-staffed. The nurse has never worked in a CCU. Which action by the nurse would be most appropriate?
Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU.
A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives?
Inform the client or legal guardian of his right to execute an advance directive.
A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives?
Inform the client or legal guardian of the right to execute an advance directive.
A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best?
Notify the charge nurse and nursing supervisor of the incident.
An older adult client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. Based on these signs and symptoms, which intervention should the nurse perform?
Notify the health care provider.
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions?
Notify the obstetrician
After a physician describes the surgical procedure for lumbar spinal fusion and its associated risks, the nurse provides a consent form for the client to sign. The client asks the nurse what the term "fusion" means and whether he'll lose a lot of blood during the procedure. Which action should the nurse take?
Notify the physician of the client's questions about the procedure before having the client sign the informed consent form.
A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP?
Reassign the UAP to a client requiring basic tasks that the UAP has mastered.
The nursing staff is devising methods to improve continuity of care. Which practice should they change to promote continuity of care?
Recorded shift report
A hospitalized client is receiving pain medication. The nurse is providing instruction to the unlicensed assistive personnel (UAP) about the care of this client. Which task would be appropriate to delegate to the UAP?
Reposition the client for comfort.
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Risk for injury
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?
Tell the parent to bring the child to the primary health care provider's office.
A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent?
The adolescent has declared himself emancipated.
A hospital is conducting a root cause analysis for a serious medication error made by a nurse that injured a client. What is the expected outcome of the root cause analysis?
The cause of the error is identified through system-wide analysis.
A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which client goal would be most appropriate?
The client will refrain from hugging other clients and change clothing only twice per day.
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in a neighboring state.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
