Dimensions Final Review
A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this information?
"I should keep personal information private, even after a client dies"
A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?
"I will put a night-light in the hallway"
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?
"May I go with my family to the visitor's lounge?"
A nurse is providing discharge teaching about home safety to an older adult client and his family. Which of the following statements should the nurse include in the teaching?
"You should install a handrail on at least one side of the stairs"
A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict-resolution styles is an example of one nurse putting aside personal hold to satisfy the other nurse?
Accommodation
Physical abuse
mandatory reporting of any suspicion of mistreatment following facility protocol
HIPAA
only those directly involved in care have access to pt chart. In room hand off, log off computer, don't share passwords
Prolapsed cord
Call for assistance ASAP. Notify provider, sterile glove insert 2 fingers, and press on either side of cord upward on presenting part. Keep baby off cord, Change position of patient: Knee-chest, Trendelenberg, side lying with rolled towel under hip. If cord prolapsed out of vagina, apply warm, sterile saline soaked towel to visible cord. continuous EFM for decels, 02 mask with 8-10 L O2, IV fluid bolus, Prepare for c-section
A nurse is assessing a client who is 24 hours post-op following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority?
Client reports muscle spasms
A nurse is planning to perform a negotiation to manage a conflict between himself and another staff member. Which of the following actions should the nurse plan to take?
Create a solution in which all parties are satisfied
Board of Nursing Authority
Issue / revoke RN license, set standards for nursing programs and delineate scope of practice for RN, LPN, and APN
A nurse suspects that a coworker may be in an impaired state when providing care to clients. Which of the following actions should the nurse take?
Report these observation to the nurse manager.
A nurse delegates the collection of a patient's temp to an AP. The nurse notes in the documentation that the AP obtained the axillary temp, however, the nurse wanted an oral temp. The nurse should identify which of the following rights of delegation should have prevented this situation from occurring?
Right communication
Rights of delegation
Right task, right circumstance, right person, right communication, right supervision
A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts?
Set up a series of meetings for all staff members to attend to discuss issues
A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take?
Tell the parent that a child protective agency must be notified.
A nurse is working with an asisitive personnel in a long term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks?
The degree of supervision that the AP will require to complete the task
A nurse in the emergency department is caring for a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse?
The parent provides a history that is inconsistent with the child's injury.
A nurse overhears two other nurses discussing a conflict they are having about who should complete certain client-care tasks. The nurses agree that they are tired of the conflict and will let the nurse manager decide who should complete the tasks. The nurse should identify this outcome as which of the following approaches to conflict management?
Win-Yield
Child abuse
always report if suspicious
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?
area with no public access
UAP suspects colleague is impaired
ask supervisor to validate suspicions by observation
Fidelity
keep promises
Non-malificence
avoid causing harm,
Beneficence
care in the best interest of patient
Maleficence
committing harm
Order to take PPE off
discard supplies, remove gloves, remove goggles, remove gown, remove mask
trash can fire in pt room
evacuate patient
Justice
fair treatment
Utilitarianism
greatest good for the greatest number ; should be overriding concern for healthcare
Veracity
honesty; tell the truth
Autonomy
right to make own personal decisions, even if it may not be in the best interest
Impaired RN
risk to client safety, due to report suspicion to management. Peer assistance programs facilitate entry to treatment program. Can be charged with criminal offense.
A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse?
Bruises at various stages of healing
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?
Gloves
A nurse has administered a medication to a client. Which of the following circumstances should the nurse identify as a medication error that resulted from a performance deficit by the nurse?
IM injection given instead of subcutaneous injection
A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first?
Manually apply upward pressure intra-vaginally on the presenting part
A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict?
Meeting one on one with the unit nurse to discuss these concerns
A nurse enters a client's room and discovers a small fire in a trash can. Which of the following actions should the nurse take first?
Move the client out of the room
Good Samaritan Laws
Protect nurses who probide emergency assistance outside of the employment location. RN must provode standard of care that is reasonable / prudent
A nurse in a pediatric emergency department is caring for 4 clients. The nurse should suspect possible abuse for which of the following clients?
a 9 month old infant who reportedly nearly drowned after climbing into the bathtub and turning on the water
A charge nurse is observing a group of new RNs. Which of the following observations should the charge nurse report to the nurse manager as a violation of HIPAA?
talking about clients with other nurses in the cafe
A nurse is teaching a group of unit nurses about the health insurance portability and accountability act. Which of the following pieces of information should the nurse include in the teaching
the security rule provides a uniform level of security to protect client records
Newborn care
warm / dry infant with sterile towel
