Custom management
A nurse is working with two assistive personnel (AP). The nurse notes that one Of the APS has been taking long breaks and making personal phone calls. Which Of the following statements should the nurse make to resolve this conflict?
"I need to talk to you about unit expectations regarding timely completion of tasks
A nurse is reinforcing teaching about legal issues with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
"I will ask permission from the client before observing a procedure the client I having.
A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion."
A nurse is assisting with the care of a group of clients on a gynecology unit. Which of the following clients should the nurse attend to first?
A client who has admitted 1 hr ago for an ectopic pregnancy
A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
Delegated tasks require follow up to ensure compliance
A nurse is caring for a group of clients for the upcoming shift. Which of the following actions by the nurse indicates effective time management?
Gather supplies for a client scheduled for a procedure.
A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?
I need to talk to you about the unit
A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about methods to reduce the cost of client care. Which of the following statements indicates an understanding of the teaching?
I should encourage clients to receive an annual influenza immunization
A nurse is reinforcing teaching with a newly licensed nurse about limit-setting for a client who exhibits manipulative behaviors. Which of the following responses by the newly licensed nurse indicates further teaching is needed?
I will bargain with the client about consequences
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities?
I will start with room 1 , then work my way to room 10.
A nurse is caring for a client who is semicomatose. The client's adult son tells the nurse that the family does not want any heroic measures performed. How should the nurse respond?
I will verify the status of the clients advanced directives
A nurse on a medical surgical unit is conducting a facility transfer with a client to an inpatient rehabilitation facility following a total hip replacement. Which of the following information should the nurse include in the transfer paperwork?
List of current medication
A nurse is caring for a client undergoing hemodialysis who will be discharged in the morning. Which of the following client statements most influences the current plan of care?
My neighbor who drives me everywhere wrecked the car this morning
A charge nurse is discussing emergency response with a newly licensed nurse. The charge nurse should identify which of the following as a triage officer during the time of a disaster?
Nurses and other emergency medical personnel
A nurse is caring for a client who has dementia and is scheduled for a procedure. Which of the following individuals should the nurse request to sign the client's informed consent?
The clients son who has a durable power of attorney
A nurse is assisting with planning an in-service for staff nurses about disaster management and triage. Which of the following color tags should the nurse include as identifying a client who requires treatment within 30 min to 2 hr?
Yellow
A nurse is delegating the collection of vital signs to an assistive personnel (AP) for a group of clients. Which of the following clients' vital signs should the nurse delegate to the AP for collection? (Select all that apply.)
[1] a client who has a history of congestive heart failure. [2] a young adult client who is 1 day postoperative following appendectomy [3] a client who is 2 days postoperative following a laparoscopic cholecystectomy
A nurse is planning to assign care activities to the assistive personnel (AP). Which of the following activities are appropriate for assignment to the AP? (Select all that apply.)
[1] accompanying a client who has depression to occupational therapy, [2] checking the position of a client who is in soft wrist restraints [3] Sitting with a client who has alcohol use disorder whose last drink was 4 days ago
A nurse is caring for a client who has heart failure notices that the client did not receive his scheduled dose of furosemide. When filling out an incident report about the occurrence, which of the following information should the nurse include? (Select all that apply.)
[1] client breath sound clear bilaterally [2] the nurse documents the client status as a result of the occurrence [3]the client statement about occurrence
A nurse is reinforcing teaching to with a client about advance directives. Which of the following topics should the nurse include? (Select all that apply.)
[1] enteral feeding tube. [2] cardiopulmonary reputation. [3] durable power of attorney for health care.
A nurse is assigning tasks for the upcoming shift. Which Of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)
[1] providing postmortem care to a client who has just passed away [2] transferring a client to radiology for x-ray s [3] performing a simple dressing change on the client's arm
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following actions jeopardize client confidentiality? (Select all that apply.)
[1] sharing a personal password with a coworker [2] discussing clients at the table in the cafeteria [3] disposing of written report sheet into the facility trash receptacle.
A nurse on a medical unit is planning the shift assignments. The nurse may delegate collection of which of the following specimens to an assistive personnel (AP)? (Select all that apply.)
[1] sputum specimen [2] stool specimen for blood [3] urinalysis specimen
A nurse is assisting with the discharge plan Of a client who has a permanent tracheostomy and breathes on his own. Which Of the following equipment should the nurse ensure is available for home care Of the tracheostomy? (Select all that apply.)
[1] suction machine [2] slit gauze pads
A nurse is assigning care for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)
[] measure a client intake and output []perform a simple dressing change []obtain a client vital signs
A nurse is reinforcing teaching with a group Of newly licensed nurses about completing an incident report. For which Of the following situations should the nurse complete an incident report?
a client family member becomes short of breath and reports chest pain
A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?
a client tells the nurse that his dentures are missing
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse attend to first?
a client who has a blood glucose level of 68 and reports mild sweting.
A nurse is caring for a group of clients. Which of the following clients should the nurse see first?
a client who has unrepaired femur fracture and new onset of confusion.
A nurse is receiving change-of-shift report for four clients. Which Of the following findings should the nurse identify as the priority?
a client who is 4 hr postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr
A licensed practical nurse is receiving change-of-shift report. Which of the following clients should cause the nurse to request a change of assignment?
a client who is to receive a unit of packed RBCs at the start of the shift.
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to see first?
a client who requests pain medication
A nurse is assisting with implementing new actions designed to reduce medication errors on her unit. Which Of the following should the nurse use to measure the effectiveness Of these actions?
a comparison of the number of medication errors before and after the actions were implemented.
A nurse is assisting a client who is 2 days postoperative following a total hip arthroplasty to walk to a chair. When the nurse offers to help the client ambulate, the client refuses to get out of bed. Which of the following actions should actions should nurse take?
acknowledge the clients wishes
A charge nurse in an acute care facility receives a client request not to have a particular assistive personnel (AP) care for her. Which of the following actions should the charge nurse take?
address the concern with the assigned nurse
A charge nurse overhears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conflict resolution?
address the situation as soon as possible
A nurse on a pediatric unit has received change-of-shift report. Which of the following clients should the nurse plan to see first?
an infant who has pertussis and is receiving oxygen via nasal cannula
A nurse is caring for four clients on a surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel (APP
assist a client to a chair who is 2 days postop following a vertical laminectomy.
A nurse is planning care for a client who has anorexia nervosa. Which of the following client goals should the nurse identify as the priority?
attaining a weight that is greater than the 75th percentile for age and height.
A nurse is preparing to perform a urinary catheterization to obtain a urine specimen for a client. The client tells the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take to alleviate the client's concern?
close the door and cover the client during the procedure
A nurse is reinforcing teaching with a newly hired assistive personnel (AP) who is assisting with the care of a client who has an indwelling urinary catheter. Which of the following instructions should the nurse give to the AP?
close the tubing clamp when transferring the client from the bed to the chair
A nurse is planning care for a group Of clients on a medical-surgical unit. Which Of the following actions should the nurse take first?
collecting data from a client who reports unilateral calf pain when ambulating
A nurse enters a client's room and finds the client on the floor. Which Of the following actions should the nurse take first?
collecting data on the cleint
A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?
collecting intake and output
A nurse is on care for a client following a stroke. Which of the following should be addressed by an occupational therapist?
completing self care
A nurse observes two assistive personnel (AP) arguing over who should go on break first. The nurse interrupts the conversation and states one AP can take break now, but the other AP will get to take an early lunch. Which of the following types of conflict management is the nurse demonstrating?
compromising
A nurse is reinforcing teaching about delegation to an assistive personnel (AP) with a newly licensed nurse. Which Of the following statements should the nurse include in the teaching?
delegation permits a designated individual to meet a goal on you behalf
A nurse is assisting with the care Of a group Of pediatric clients. Which Of the following actions should the nurse take first?
deliver a breakfast tray to a child who has been administered regular insulin.
A nurse mistakenly administers a dose of metformin within 1 hr of the previous dose. Which of the following findings should alert the nurse that the client is experiencing an adverse effect from the medication error?
diaphoresis and tachycardia
A charge nurse in a long-term care facility has assigned care for a group of clients to an assistive personnel (AP). The charge nurse observes the AP chatting sociably with peers, learns that the AP left the unit without communicating the absence, and receives reports from clients about lack of care by the AP. Which of the following actions should the charge nurse take first?
discuss the assigned task with the AP
A nurse asks an assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?
discuss thee incident with the AP
A nurse applies wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse take?
document. what. less restrictive interventions she tried
A nurse is assisting with the admission Of a client who has meningococcal pneumonia. Which Of the following isolation precautions should the nurse initiate?
droplet
A nurse is caring for a client who is postoperative following an abdominal hysterectomy and has an indwelling urinary catheter in place. An assistive personnel (AP) reports to the nurse that the client's abdominal dressing is saturated with blood. Which of the following tasks should be delegated to the AP?
emptying the urinary collecting bag
A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?
encourage the client to cough and deep breathe
A medical surgical unit has implemented a policy change. The nurse manager has noticed that one of the nurses, who has a history of being resistant to change, is not delivering care according to the new policy. Which of the following actions should the nurse manager take?
encourage the nurse to verblize the reasons for resistance to the change.
A nurse is preparing to administer a medication to a client. Which Of the following actions by the nurse demonstrates advocacy for client rights?
encouraging the clients to verbalize questions or concerns
A nurse is assisting with revising a facility's emergency response plan for tornado disasters in the community. The nurse should plan to collaborate with which of the following agencies?
federal emergency management agency (FEMA)
A nurse on a unit is working with an assistive personnel (AP). Which Of the following tasks should the nurse have the AP perform first?
feed a school age client who has burns on both upper extremities
A nurse is reviewing disaster management with a newly licensed nurse. Which Of the following actions should the nurse identify as being the responsibility Of the nurse during a disaster?
focus on providing care that prevents life threatening emergencies
A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?
ill notify the charge nurse of your request to have only male staff members assigned to care for you.
A licensed practical nurse (LPN) is planning care for a group of clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the LPN perform?
insert an NG tube for a client who has abdominal distention
A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
measure the output from a clients urinary catheter.
A nurse is reinforcing teaching about advance directives with a client admitted to the hospital and is scheduled for surgery. Which of the following statements made by the client indicates a need for further teaching?
my children can make changes tony living will if I am incapacitated
A nurse notes that a provider frequently arrives to the unit with bloodshot eyes and smelling like alcohol after lunch. Which of the following actions should the nurse take?
notify the nurse manager or charge nurse about the concerns.
A nurse is caring for a group of clients on a medical surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (APP
observe a confused surgical client who has multiple tubes
A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?
obtain consent from a relative.
A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?
obtain the client vital signs
A nurse is delegating tasks to an assistive personnel (AP). Which of the following task should the nurse assign to the
obtaining vital sings on clients who are stable.
A client has been waiting for discharge medications from the pharmacy for more than 2 hr. Which Of the following actions should the nurse identify as an opportunity for performance improvement in this area?
participating on a work team that includes pharmacy and nursing staff.
A nurse is preparing to administer medication to client. Which of the flowing client identifiers should the nurse use prior to administering medication to the client?
phone number
A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?
place sequential compression devices bilaterally.
A nurse is preparing to perform a urinary catheterization for an older adult client who speaks a different language than the nurse. Which of the following actions should the nurse take to explain the procedure to the client?
provide an interpreter to explain the procedure
A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
providing postmortem care on a client who has died,
A nurse enters the hospital cafeteria for lunch and overhears two assistive personnel (AP) discussing a client who is currently hospitalized. Which of the following actions should the nurse take?
quietly tell thee APs that the conversation is inappropriate
A nurse is planning care for a group Of clients and reviewing tasks to be delegated the assistive personnel (AP). Which Of the following tasks should the nurse complete?
removing and cleaning of the cannula of a client who has a new tracheostomy.
A nurse is delegating tasks for an assistive (AP) to perform for a client who is 1 day postoperative following abdominal surgery. Which of the following tasks should the nurse perform herself?
removing the abdominal dressing.
A float nurse is given a client assignment that requires the use Of unfamiliar skills and techniques. Which Of the following actions should the nurse take?
request the charge nurse to modify the assignment
A charge nurse in a long-term care facility checks with other nursing personnel on the unit throughout the day to determine if they are completing tasks. Which of the following rights of delegation is the nurse demonstrating?
right supervision
A nurse requests that an assistive personnel (AP) change all the linens and give bed baths to four clients on the unit. The previous day, the AP was not able to complete these same tasks. Which of the following actions should the nurse take in addressing this situation?
set a time frame for the AP to complete the tasks the assignment includes.
A charge nurse is asked to witness a surgical consent form. Upon entering the room, the client asks, "Are there other options besides surgery?" Which of the following responses should the nurse give?
several treatment options are available for your disease. have you discussed this with your provider?
A nurse observes another nurse performing a in the incorrect sequence. The procedure does not harm the client. Which of the following actions should the nurse take first?
speak with the nurses privately
A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?
speaks in short phrases
A nurse is caring for a client who is experiencing dysphagia. Which of the following referrals should the nurse request at this time?
speech therapist
A nurse enters the room Of a client who is confused and finds the client sitting on the floor. After determining that the client is free from injury, and completing an incident report which Of the following actions should the nurse take?
submit thee incident report to the risk manager
A nurse is care for several clients with the help of an assistive personnel (AP). Which task should the nurse ask the AP to perform first?
take an ABG specimen to the lab.
A nurse is reinforcing teaching about interdisciplinary care plans with a group Of newly licensed nurses. Which Of the following statements should the nurse include in the teaching?
the care plan is designed to improve continuity of client care
A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which Of the following statements should the nurse include as part Of the background component Of the SBAR communication tool?
the client has a history of hypertension
A nurse is providing change-of-shift report to the oncoming nurse. Which of the following information should the nurse include in the report?
the client in room 108 has Benn prescribed a new pain med.
A nurse is caring for a client. One of the client's family members requests to view the client's medical record. Which of the following responses should the nurse make?
the client must provide written permission to share the record
A nurse has received report from an RN on a group of newly assigned clients. Which of the following statements by the RN during report indicates that the nurse should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
the client's blood pressure and pulse have been unstable.
A charge nurse in a long-term care facility is reviewing client outcomes when delegating tasks to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?
the final step in delegation is evaluation of the outcomes.
A nurse witnesses an adult who is experiencing a cardiac arrest while at the grocery store. The nurse performs CPR. Which of the following criteria is necessary for the Good Samaritan law to provide civil immunity for the nurse?
the nurse has basic life support certification
A nurse is caring for a group of clients on a medical-surgical unit. The nurse delegates various tasks the clients require to another licensed practical nurse (LPN) and an assistive personnel (AP).The nurse should identify that the responsibility for making sure the client received the care the plan of care specifies belongs to which of the following team members?
the nurse who delegates tasks
A nurse is caring for a client who is scheduled for a transurethral resection of the prostate (TURP). Which of the following statements by the client indicates that informed consent was provided?
there is a chance I may become impotent
A nurse is caring for a client who is to undergo a total knee arthroplasty. Which of the following actions should the nurse take when participating in the informed consent process?
verify the client is giving consent voluntarily
A nurse is caring for an infant who has respiratory syncytial virus. Which of the following actions should the nurse take?
wear a gown when changing the infants diaper
A nurse is caring for a group of clients with the help of an assistive personnel (AP). Which of the following determinations must the nurse make before delegating a client care task to the AP?
whether the task is within the AP job description.
A nurse is caring for a client who is scheduled for a surgery. The client states, "l have changed my mind and I don't want the surgery." Which Of the following responses should the nurse give?
you cam change your mind about the surgery at any time
A nurse is obtaining informed consent from a client who is scheduled for a total hip arthroplasty. Which if the following statements should the nurse include?
your provider will discuss other treatment options.
