Leadership & Management - Archer Review (2/2)

Choice B is correct. If the nurse has found an unconscious and pulseless patient, they should begin chest compressions. Immediate chest compressions are the most effective way to maintain total body oxygenation.

An emergency response nurse has just arrived on the scene of a 911 call. The patient is unconscious and without a pulse. The nurse's priority action is to: A. Administer two rescue breaths. B. Begin chest compressions. C. Check the patient for a patent airway. D. Ask another health care professional to check the carotid artery.

Choice C is correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription should be implemented immediately as the risk of seizure activity is quite significant.

The nurse has received the following prescriptions for newly admitted clients. The nurse should first A. irrigate a wound for a client with a stage III pressure ulcer. B. complete pin care for a client with a halo fixation device. C. administer diazepam for a client with delirium tremens (DTs). D. insert an indwelling urinary catheter for a client with retention.

Choice C is correct. The patient may revoke either a living will or durable power of attorney at any time, and this can be done either verbally or in writing.

The nurse is discussing information about advanced directives with a patient who expresses concerns, asking, "What if I change my mind about what I want?" What approach would you use to respond to the patient's care? A. Explain that the patient would have to file a new witnessed document in order to make any changes. B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document. C. Assure the patient that he can change or revoke his advanced directives at any time. D. Advise the patient that changes could not be made during this hospital stay.

Choice C is correct. UAPs may apply and maintain sequential compression devices. These devices are instrumental in providing mechanical prophylaxis against venous thromboembolism.

The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)? A. The initial ambulation of a client following a laparoscopic hernia repair. B. Removal of a Jackson-Pratt drain for a client three days post-operative. C. Applying sequential compression devices to a client's lower extremities. D. Calling in prescriptions to the local pharmacy for a client ready for discharge.

Choice D is correct. These manifestations indicate that the client may be beginning labor. True labor manifestations include contraction patterns of increasing frequency, duration, and intensity. The contractions tend to increase with walking and may start in the lower back and gradually sweep around to the lower abdomen. Considering the client's gestational age and manifestations, this client requires immediate follow-up.

The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is A. 16 weeks of gestation and reports a fluttering sensation B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet D. 38 weeks of gestation and reports lower back pain that increases with walking

Choice A is correct. By a client providing their consent, this is respecting their decision and, thus, their autonomy. This ethical principle exemplifies the patient's self-determination and ability to make their own choices without interference or coercion.

The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle? A. Autonomy B. Justice C. Paternalism D. Veracity

Choice A is correct. Vital signs are essential to obtain, which will help the nurse determine which client should be seen first by the nurse. If a client's vital signs are unstable, the nurse must prioritize the client's care. Getting clients simultaneously is common, and a strategy a nurse may use to help differentiate which client is stable or unstable is obtaining vital signs.

The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first? A. Vital signs B. Number of prescribed medications C. Medical history D. Code status

Choice B is correct. Witnessing consent is within the scope of an RN. The client needing emergency surgery will require the RN's initial attention to avoid a delay in care. While the primary healthcare provider (PHCP) may override consent, this is usually reserved for clients who cannot communicate because of their condition.

The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Teaches a client scheduled for discharge how to ambulate with crutches. B. Witnesses informed consent for a client needing an emergency laparotomy. C. Irrigates a client's ostomy who reports abdominal cramping. D. Calculates the intake and output of a client with diabetes insipidus (DI).

Choice A is correct. In Benchmarking, the nurse-manager compares best practices from top hospitals with her unit and adapts the unit's methods to improve unit performance.

The nursing director calls for a meeting of all nurse managers in the facility. She has just come back from a visit to another hospital that was recently commended for its superior patient care. She aims to formulate similar policies to improve patient care in their facility. The nurse manager is performing which management initiative? A. Benchmarking B. Continuous Quality Improvement C. Performance Improvement D. Quality Management

Choice B is correct. As the supervising nurse on your client care unit, you should investigate and explore the near misses similar to how you deal with sentinel events. Near misses, such as these inaccuracies, should be reported per hospital policy to be studied and examined to circumvent future errors.

You are assigned to supervise a client care unit. Over the last several months, the nurses in the unit have told you that the unit dose dispensing of medications by the pharmacy has not been accurate at all times. Fortunately, there have been no medication errors as a result of these inaccuracies. Which of the following actions should be prioritized? A. Praise the staff for catching these inaccuracies B. Investigate and explore these near misses C. Investigate and explore these medical errors D. Report these inaccuracies to the State Department of Health

Choice C is correct. Singed eyebrows and a hoarse voice are suggestive of a smoke inhalation injury. Considering this is an airway concern, this client should be prioritized.

The emergency department (ED) nurse is caring for a group of clients following an industrial accident. It would be a priority for the nurse to follow up on the client who A. has a fracture to the lower extremity and increasing pain. B. is crying because they cannot locate their child. C. has singed eyebrows and a hoarse voice. D. is diabetic, and their insulin pump has been lost.

Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI.

A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? A. Obtain a 12-lead electrocardiogram B. Provide supplemental nasal cannula oxygen C. Established intravenous (IV) access D. Auscultate lung sounds

Choice D is correct. The appropriate and initial nursing action is to inquire with the client about their rationale for refusing the medication. Assessment is the initial part of the nursing process, and discussing the refusal with the client is a step the nurse should execute.

A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take? A. Document the refusal B. Notify the primary healthcare provider (PHCP) C. Review the client's most recent platelet count D. Inquire with the client about the refusal

Choice A is correct. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit.

A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as: A. Autocratic B. Democratic C. Participative D. Laissez-faire

Choices B, C, D and E are correct. The language used to describe the types of disciplinary actions available to the Board of Nursing (BON) varies according to state law. Although the terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Board actions may include: Fine or civil penalty Referral to an alternative discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other mental or physical conditions) Public reprimand or censure for a minor violation of the nurse practice act often with no restrictions on the license The imposition of requirements for monitoring, remediation, education, or other provision tailored to the particular situation Limitation or restriction of one or more aspects of practice (e.g. probation with certain limits, limiting role, setting, activities, hours

A nurse manager is preparing a seminar for new hires. Which of the following may be causes for disciplinary action taken by the Board of Nursing? Select all that apply. - Asking visitors to leave the room when preparing to assess a patient. - Testing positive on a routine drug test. - Refusal to provide care to a client based on personal beliefs. - Committing a breach of patient confidentiality. - Negligence

Choice D is correct. By allowing the newly hired nurse to work with a preceptor, as suggested by Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the preceptor would be able to assess and evaluate clinical competency and subsequently identify areas that required additional training.

A nurse manager oversees a unit with a newly hired nurse currently in the orientation phase of employment. The unit is faced with a situation where the newly hired nurse is needed to perform client care. Which practice is within the requirements of the Joint Commission on the Accreditation of Health Care Organizations (JCAHO)? A. Do not let the newly hired nurse perform any duties until orientation is completed. B. The newly hired nurse may perform client care since they are currently licensed. C. Provide the newly hired nurse with the necessary educational modules and other materials and allow the nurse to proceed with client care. D. Pair the newly hired nurse with a preceptor to assist with client care while assessing competency.

Choice A is correct. It is appropriate for the RN to delegate to the LPN/VN to collect data on the client's neurovascular status (pulse, skin condition, capillary refill) every two hours while the client is restrained. Data collection does not require analysis, and the PN can collect data such as auscultating lung sounds, data collecting on a client's skin integrity, collecting vital signs, and collecting a client's health history.

A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN? A. Collect data on the client's skin integrity. B. Educate the client on the need for restraints. C. Initiate peripheral vascular access. D. Continually assess the client to determine if restraint use is necessary.

Choice A is correct. Retractions demonstrate increased respiratory effort, meaning the pediatric client is in respiratory distress. Since retractions are a medical emergency and this pediatric client is exhibiting inspiratory retractions, thus indicating respiratory distress, this client should be the first client the nurse assesses.

A registered nurse arrives for a shift in a pediatric emergency department (ED). There are four pediatric clients in the ED. Which client would the nurse assess first? A. A one-month-old infant that is crying with retractions during inspiration B. A 5-year-old with pneumonia and a 95% pulse oxygen saturation C. A 10-year-old with diarrhea and vomiting and a potassium level of 3.6 mEq/L D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL

Choices A, B, C, and D are all correct. All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Docume

According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Select all that apply. Right task Right circumstance Right person Right direction and communication

Choice B is correct. Floating to the mother-baby unit and identifying tasks within her training that she can safely perform is the correct action. This promotes patient safety and benefits both the nurse and the unit.

After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate? A. Refuse the assignment. B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. C. Call the nurse manager. D. Float to the mother-baby unit and ensure no one knows about her inexperience.

Choices B, C, and D are correct. B is correct. LPN/LVN training allows nurses to do tasks with the most predictable outcomes, including passing oral medication to stable clients. LPNs/LVNs can administer routine medications under the RN's supervision. C is correct. LPN/LVN training allows nurses to do tasks with the most predictable outcomes, such as removing a Foley catheter. D is correct. LPN/LVN training allows nurses to do tasks with the most predictable outcomes, such as completing routine dressing changes.

The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, which ones can be safely delegated to an experienced LPN/LVN? Select all that apply. - Completing an admission assessment on a new patient - Administering routine oral medications to stable patients. - Removal of a urinary catheter - Completing a dressing change - Administering an initial dose of a new medication to a patient.

Choice C is correct. Recording intake and output is a skill within the scope of a UAP. This task may be appropriately delegated to a UAP to complete.

The charge nurse is assigning tasks to a unlicensed assistive personnel (UAP). Which task would be appropriate to delegate? A. Collecting a urine specimen from an indwelling urinary catheter. B. Increase nasal cannula oxygen for a client by one liter a minute. C. Record how much drainage is in the suction cannister. D. Remove a nitroglycerin patch before giving a bath.

Choices A and F are correct. When making client assignments, the LPN should be assigned to a stable client with a predictable outcome. A client receiving antibiotics for lower extremity cellulitis is a low acuity illness and may be cared for by the LPN. Scheduled tube feedings and colostomy irrigations are within the scope of an LPN, and this can be delegated.

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN? Select all that apply. A client - receiving oral antibiotics for lower extremity cellulitis. - newly admitted with an exacerbation of myasthenia gravis. - with a chest tube and receiving mechanical ventilation. - requiring a referral to an outpatient support group. - needing to receive intramuscular RhoGAM. - needing scheduled tube feedings and colostomy irrigations.

Choices A, D, and F are correct. When making client assignments, the RN should be assigned to the unstable client who has the least predictable outcome and may require frequent assessment or teaching. A client newly diagnosed with type II diabetes mellitus will require a large amount of teaching. A client with an AKI and hyperkalemia is at risk for cardiac instability. Finally, a client experiencing acute coronary syndrome receiving IV nitroglycerin will need frequent assessment because of the unpredictable nature of the condition.

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? Select all that apply. A client - A client newly diagnosed with type II diabetes mellitus. - requiring sterile dressing changes to an infected wound. - who requires enteral feedings and tracheostomy care. - with an acute kidney injury (AKI) with a potassium 5.6 mEq/l [(3.5-5 mEq/L) (3.5-5.0 mmol/L)] - who is two days post-operative following a mastectomy. - receiving intravenous nitroglycerin for acute coronary syndrome.

Choice B is correct. When the nursing unit is short-staffed, non-essential tasks may be delayed. Daily baths are a non-essential task compared to medication administration, vital sign collection, and hourly safety rounds.

The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs? A. Medication administration B. Daily baths C. Vital sign collection D. Hourly safety rounds

Choice A is correct. This activity is appropriate to be delegated to the LPN/VN. The LPN/VN may perform sterile and non-sterile dressing changes and wound care. This would not be an appropriate task for a UAP as it is outside their scope of practice.

The charge nurse plans client care assignments for a unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources? A. Perform wound care and dressing changes B. Collect routine vital signs (VS) C. Turn all bedbound clients every two hours D. Ambulate clients with ambulation orders

Choices C and F are correct. The client with angina and ST-segment changes should be assigned to the RN because of this client's clinical unpredictability. Angina accompanied by ST-segment changes is a worrisome sign of acute coronary syndrome. A 59-year-old requiring chronic wound care and the insertion of an indwelling catheter is more appropriate for the LPN to ensure an evenly divided client assignment. These are skills (wound care and indwelling catheter insertion) within the scope of an LPN. While an RN may assume this client, to maximize staff resources, this client should be assigned to the LPN.

The charge nurse reviews staff assignments for one registered nurse (RN) and one licensed practical/vocational nurse (LPN/VN) on the nursing unit. To maximize staff resources, which client assignments require modification to be congruent with each nurse's scope of practice? See the image below.Select all that apply.

Choice C is correct. The client is suffering from morphine toxicity. The nurse needs to administer the antidote, which is naloxone (Narcan).

The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate? A. Prepare for intubation. B. Prepare to administer a dopamine infusion. C. Administer naloxone. D. Start an IV infusion of normal saline.

Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. The nurse must protect the other clients and staff from disease transmission. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing surgical mask in the client's presence.

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. B. Place the client on droplet precautions. C. Notify the public health department. D. Obtain prescribed blood cultures.

Choice C is correct. This client's mean arterial pressure (MAP) is critically low. The MAP for an adult should be at least 60 mm Hg (this will ensure adequate perfusion to critical organs), with the ideal MAP being 70 mm Hg. This client's MAP requires immediate correction because of the end-organ damage the client is likely experiencing.

The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up? A. Respiratory rate (RR) 23/minute B. Capillary blood glucose 319 mg/dL C. Mean arterial pressure (MAP) 51 mm Hg D. PaO2 90 mm Hg

Choice B is correct. The nurse should prepare for the delivery of the newborn because of a presenting fetal part. The nurse transporting the client to L&D would be highly inappropriate because the client could deliver the newborn during transport which is not safe. Finally, the nurse should prepare for the delivery of the newborn because the presenting part requires immediate application of fetal heart monitoring to determine the stability of the neonate.

The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. The nurse should take which priority action? A. Assess the client's previous obstetric history B. Prepare for the delivery of the newborn C. Transport the client to the labor and delivery unit D. Time the frequency and duration of contractions

Choice D is correct. For the infant choking on a foreign body and conscious and not making any noises, the nurse should immediately give five back blows and five chest thrusts. The nurse should place the baby face down on the forearm to do this. With the arm resting on your thigh and with the heel of your other hand, give the child five quick, forceful blows between the shoulder blades. If this is ineffective, the nurse should turn the infant on its back so that the head is lower than the chest. Place two fingers in the center middle of the breast bone, just below the nipples. Press inward rapidly five times.

The emergency department (ED) nurse is caring for an infant who is choking on a foreign object. On assessment, the infant is conscious and not making any noises. The nurse should immediately A. begin chest compressions at 100-120/minute. B. attempt a blind finger sweep in the mouth. C. perform abdominal thrusts. D. give five back blows and five chest thrusts.

Choices A, D, and E are correct. These client situations require a triage of non-urgent. The non-urgent triage category signifies that the client can be placed in the waiting area for a set of times without risking clinical deterioration.

The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? A client Select all that apply. - with a localized abscess on the right leg. - reporting that they have chest pressure. - with nausea, vomiting, and painful urination. - requesting a refill of their prescribed antidepressant. - with a single laceration to the left hand.

Choice A is correct. This client is the priority because strong evidence of internal bleeding is evident. Clients with hemophilia often bleed at the joints (ankles and knees) because they absorb the most impact. This client's situation is quite serious because they report dizziness, which is also collateral support for internal bleeding. This client should be prioritized.

The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with A. hemophilia reporting knee and ankle stiffness with dizziness. B. chronic obstructive pulmonary disease (COPD) reporting a productive cough. C. chronic pericarditis reporting intermittent chest pain during inspiration. D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.

Choice D is correct. This client sustained a nasal fracture caused by facial trauma, which may have consequently caused brain trauma. Vomiting is an early manifestation of increased intracranial pressure requiring immediate follow-up. The nurse should notify the physician of the condition change and prepare the client for an immediate computed tomography (CT) scan of the head to confirm the findings. Interventions the nurse should take are keeping the client's head of the bed elevated between 30-45 degrees and the client's head neutral. This may help mitigate some of the increasing ICP. Other findings associated with increased ICP include restlessness, altered level of consciousness, and headache.

The emergency department nurse cares for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up? A. shallow respirations B. chest pain with repositioning C. bruising on the chest D. vomiting

Choice C is correct. Restocking PPE is a helpful task and within the scope of a UAP. Having PPE that is accessible is crucial to ensuring adherence by staff and visitors. PPE should be kept in clean and dry areas.

The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)? A. Educate staff members on actions to reduce central line-associated bloodstream infections B. Demonstrating correct handwashing techniques to visitors C. Restocking personal protective equipment (PPE) D. Screening visitors for respiratory infections

Choice D is correct. Teaching the client how to use the call light is essential, especially since the client is an older adult and had a previous fall. A fall prevention strategy is to ensure the client has a reliable method to obtain assistance from nursing staff.

The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client A. how to use the telephone and order meals. B. their prescribed medications for the shift. C. the prescribed pain management plan. D. how to operate the call light.

Assess the injury while calling for help Cover the open wound with a clean dressing Elevate the arm Apply an ice pack to the site around the fracture

The nurse at the summer camp is caring for a child who sustained a compound fracture of the arm following a fall. Place the following actions in order of nursing priority when dealing with this injury: Elevate the arm Assess the injury while calling for help Cover the open wound with a clean dressing Apply an ice pack to the site around the fracture

Choice C is correct. An overdose of lithium may be fatal if not treated. Lithium has a narrow therapeutic index (0.6-1.2 mEq/L), and manifestations of toxicity include gastrointestinal symptoms of nausea, vomiting, and diarrhea predominate, and neurologic symptoms are delayed. The neurological findings may consist of confusion, ataxia, and coarse tremors. Obtaining vital signs is a priority to determine the client's overall health status.

The nurse cares for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially A. developing a therapeutic rapport with the client. B. inserting a peripheral vascular access device. C. obtaining the client's vital signs. D. collecting a serum lithium level on the client.

Choice A is correct. An aortic aneurysm dissection is an emergency. When urgent surgery is needed for a life-threatening diagnosis and if the client is not in a position to give consent, delaying the surgery to obtain informed consent may result in the client's morbidity or death. Reasonable efforts can be made to notify the family if they can be contacted promptly. However, if the family cannot be located or reached promptly, surgery should still proceed without the need for informed consent.

The nurse cares for an unconscious client with a dissecting aortic aneurysm that needs urgent surgery. The client's family cannot be tracked. The nurse's priority action is: A. Send the client to surgery. B. Call the hospital lawyer. C. Search for all the client's contacts who can provide informed consent. D. Notify the nursing supervisor on-call and request their permission to waive informed consent.

- I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome. - Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin. - He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression. - His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given. - Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for int

The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Place the communication steps to follow the identification, situation, background, assessment, and recommendation (ISBAR) format. Place each piece of communication in the appropriate order. - Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion. - His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given. - Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin. - He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression. -

Choice C is correct. Negligence is an unintentional tort and is defined as the failure of a person to exercise the degree of care that an ordinarily prudent person would have exercised under similar circumstances. This is deemed malpractice when the nurse is committing these infractions in a professional capacity. Malpractice is the failure of a professional person to act as other prudent professionals with the same knowledge and education would have acted under similar circumstances. The failure of the nurse to communicate with the physician a critical laboratory result in a timely manner is classic negligence/malpractice. Other examples of negligent acts include - Failure to follow standards of care Failure to use equipment in a responsible manner Failure to communicate Failure to document Failure to assess and monitor Failure to act as a client advocate

The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit? A. The nurse documents care under another nurse's username and password B. The nurse takes pictures of a client's medical record and distributes them online C. The nurse does not notify the physician of a client's critical laboratory result D. The nurse treats their spouse in the acute care facility with prescribed medications

Choice D is correct. The client's vomiting following a tonsillectomy requires immediate follow-up because vomiting and coughing may trigger hemorrhage. This client requires immediate follow-up so the nurse may treat the vomiting with prescribed anti-emetics and assess the client for potential hemorrhage.

The nurse has become aware of the following client situations. The nurse should first assess the client A. with chronic obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reporting a productive cough. B. who had a laparoscopic cholecystectomy three hours ago and is reporting right shoulder pain and abdominal cramping. C. with ulcerative colitis, who had three bloody stools in the past two hours and reporting abdominal cramping. D. two hours postoperative following a tonsillectomy and is reporting throat pain while vomiting.

Choice D is correct. One of the dreaded complications of pneumonia is acute respiratory distress syndrome (ARDS) which is manifested by hypoxia. The client demonstrating confusion and restlessness is quite concerning for hypoxia. The nurse should quickly assess the client and intervene by calling a rapid response if this should occur in the acute care setting.

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client A. with a chest tube that has tidaling in the water seal chamber. B. that is receiving mechanical ventilation and is occasionally biting on the tube. C. that is receiving albuterol via a nebulizer and reports headache and nervousness. D. with pneumonia that has become restless and confused.

Choice A is correct. The priority is to attend to a client's physiological needs. Initiating intravenous fluids for a client with anorexia nervosa prioritizes over the other prescriptions because of the condition's ability to cause dehydration and severe fluid and electrolyte disturbances.

The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following? See the image below. A. initiate intravenous fluids to a client with anorexia nervosa. B. administer venlafaxine to a client with persistent depressive disorder. C. consult the social worker to begin discharge planning for a client. D. obtain a blood sample to evaluate a client's lithium level.

Choice B is correct. A 26-year-old female requiring a one-person assist in ambulating to the restroom would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in assisting clients with ambulation and this is within their scope of practice.

The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel? A. A 65-year-old male requiring sterile dressing changes. B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube. D. A 16-year-old female who is 4 hours post-cardiac catheterization.

Choice B is correct. The nurse should prioritize seeing the client with multiple saturated peri-pads first. This is indicative of heavy bleeding, which can be a sign of postpartum hemorrhage (PPH), a potentially life-threatening condition. Rapid assessment and intervention are crucial in cases of PPH because it can lead to severe complications, including hypovolemic shock. By promptly attending to this client, the nurse can initiate appropriate measures such as fundal massage, administering uterotonic medications, and closely monitoring vital signs to address the hemorrhage and prevent further complications.

The nurse in the Women's Health Unit has just finished receiving the report from the previous shift. Which client should the nurse see first? A. A client who is complaining of perineal pain while voiding. B. A client who had multiple saturated perineal pads changed during the night. C. A client who is refusing her newborn to be roomed in with her. D. A client who is upset because her baby will not latch.

Choice D is correct. The nurse's primary responsibility is client safety. For the client that is deaf and blind, it is critical to provide a safe environment. Visual impairment has been associated with falls that often result in fractures and dislocations. A client with visual impairment may experience disorientation as a consequence of being in a strange hospital environment.

The nurse is admitting a client who is blind and deaf. The nurse should prioritize which action? A. Review the plan of care with the client B. Communicate with the nursing supervisor with any safety concerns C. Update the client on the social activities D. Provide a safe environment for the client

Choice A is correct. The normal range for serum calcium is 9-10.5 mg/dL. This client's serum calcium level is above 10.5 mg/dL; therefore, the client is experiencing hypercalcemia. At a calcium level of 14 mg/dL, most clients may experience symptoms. Often, these may include polyuria, polydipsia, and dehydration. If not addressed, clients may develop renal failure and altered mental status. The nurse must notify the physician regarding this abnormal lab value.

The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL(9-10.5 mg/dL). What is the priority action the nurse should take? A. Notify the physician B. Document the finding C. Continue to monitor the patient D. Remove the patient from the telemetry monitor

Choice A is correct. Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them.

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package B. Open the package to review its content C. Provide the package upon discharge D. Determine if the sender is the client's next of kin

Choice B is correct. The nurse should prioritize notifying the healthcare provider about the serum potassium level. Captopril, an ACE inhibitor, can cause hyperkalemia. Hyperkalemia can lead to cardiac arrhythmias and other serious complications.

The nurse is caring for a client taking prescribed captopril. What abnormal laboratory values should the nurse prioritize when notifying the healthcare provider? A. Serum creatinine 1.3 mg/dL [Male: 0.6-1.2 mg/dL] B. Serum potassium 5.2 mEq/L [3.5-5 mEq/L] C. Serum phosphorus 4.6 [2-4.5 mEq/L] D. Blood glucose 135 mg/dL [70-110 mg/dL]

Choice C is correct. Occupational therapists are excellent resources for helping clients suffering from gait and movement problems. Occupational therapists help clients transition from their hospital life to their homes. While physical therapists are mostly involved in specific gait-related issues, occupational therapists also assist in helping improve functional mobility so that the clients can perform their activities of daily life ( ADL).

The nurse is caring for a client who is recovering from a transient ischemic attack and can walk but is having difficulty going upstairs. What professional should visit them to help work through this issue? A. Case manager B. Nurse practitioner C. Occupational therapist D. Respiratory therapist

Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, one of the earliest manifestations of shock, and the nurse needs to assess the client further.

The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up? A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain) B. Oral temperature of 99.5°F (37.5°C) C. Heart rate of 112 beats-per-minute (BPM) D. Hypoactive bowel sounds in all four quadrants

Choice A is correct. A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock.

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). B. has an indwelling urinary catheter and reports burning at the insertion site. C. has scant blood in their newly established ostomy pouch. D. has friends writing words on their fiberglass cast with different colored markers.

- A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. - A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. - A 31-year-old client three days post-operative who requires a sterile dressing change. - A 51-year-old client who has a discharge prescription following a heart failure exacerbation.

The nurse is caring for a group of clients. Which client should the nurse see first? Place the clients in order based on the priority that the nurse should see them. - A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. - A 51-year-old client who has a discharge prescription following a heart failure exacerbation. - A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. - A 31-year-old client three days post-operative who requires a sterile dressing change.

Choice D is correct. The collection of vital signs may be delegated to a UAP. This includes pulse, blood pressure, temperature, and oxygen saturation.

The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Apply nasal cannula oxygen B. Remove a vascular access device that is not patent C. Perform venipuncture for laboratory work D. Obtain vital signs every four hours

Choice A is correct. The 'living will' is a legal document expressing the patient's preferences regarding life-extending medical procedures. It is the nurse's responsibility to support the patient's right to autonomy and self-determination, as shown in that document. One strategy to do so is to communicate the patient's wishes to the health care team involved with the patient.

The nurse is caring for an elderly patient who has become comatose. The patient's living will specifies that no life-extending procedures are to be done. However, the patient's adult children are troubled and strongly object to this. How would the nurse effectively advocate for the patient in this situation? A. Remind colleagues about the contents of the patient's advance directives. B. Document the wishes of the patient's adult children. C. Plan to respond slowly or incompletely should the patient experience cardiac arrest. D. Develop a plan of care based on the preferences of the patient's children.

Choice A is correct. This client is demonstrating signs of aggression (mumbling, pacing), and the nurse should intervene to avoid any escalation and to prevent disruption to the milieu. Manifestations of aggressive behavior include pacing, hyperactivity, a rigid posture, clenched jaw or fist, mumbling to themselves, intense eye contact, or stone silence. The client's diagnosis of psychosis also supports intervention from the nurse because psychosis features impulsivity and irrational acts.

The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves. B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands. C. has a substance use disorder and refuses to attend group therapy for the second time. D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.

Choice A is correct. Levofloxacin should be promptly administered for this client with pneumonia. Critical pathways call for prompt initiation of antibiotics for pneumonia as the condition may worsen to acute respiratory distress syndrome (ARDS) and/or sepsis. The diagnosis of pneumonia is also prioritized as it is a breathing impediment and requires prompt follow-up.

The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit. View Exhibit A. Levofloxacin 750 mg IVPB Q12 hours B. 0.9% Saline 125 ml/hr C. Metoclopramide 10 mg IV Push Q8 hours D. Ketorolac 15 mg IV Push Q8 hours

Choice A is correct. Following a femoral angioplasty, the affected extremity should be assessed for a pulse, and the client should be instructed to report any decreased sensation. A common complication following this procedure is arterial occlusion which causes a decreased pulse and the client to experience a reduced sensation (or paresthesias).

The nurse is caring for assigned clients. The nurse should initially assess the client who A. is recovering from a femoral angioplasty and reports their foot is falling asleep. B. has diabetes mellitus and refused their prescribed glargine insulin. C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14. D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.

Choice A is correct. A complication of transsphenoidal hypophysectomy is meningitis. The client needs to be immediately assessed for other manifestations of meningitis, including photophobia, nuchal rigidity, and altered mentation. Complications following this surgery include CSF leakage, infection, optic nerve damage, and diabetes insipidus.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who is A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C). B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side. C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous. D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.

Choices A, B, C, and D are correct. The nurse arranging for an interdisciplinary conference, consulting with case management, initiating outpatient referrals, and performing post-discharge phone calls are all relevant to effective care coordination. These actions work to improve care delivery through effective communication with other members of the healthcare team.

The nurse is caring for assigned clients. Which of the following actions would reflect effective care coordination? Select all that apply. - Arranging for an interdisciplinary conference - Consulting with case management for a discharge plan - Initiating appropriate outpatient referrals - Performing post-discharge phone calls - Implementing transmission-based precautions

Choices B and E are correct. An interdisciplinary care conference is where the nurse can get the necessary medical professionals to develop one big care plan for the client. A client with an ischemic stroke with hemiplegia will require interdisciplinary care such as occupational and physical therapy. Further, the client may require subacute rehabilitation provided by nursing. A client with a fractured tibia and fibula will require physical therapy and social services consultation to assist the client with housing.

The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply. - pulmonary tuberculosis with multiple prescriptions. - ischemic stroke who has left-sided hemiplegia. - hyperthyroidism and is scheduled for a thyroidectomy. - stage one Alzheimer's disease who lives with family. - fractured tibia and fibula and is homeless. - end-stage-renal disease who refuses dialysis.

Choice B is correct. This conversation being observed by the nurse may violate the client's confidentiality. Conversations about a client's personal medical information (PMI) should be kept private and involve only those involved in the client's care. This is considered the right to know, which mandates that information be safeguarded and limited in how it is shared.

The nurse is in an elevator and observes two staff members discussing a client's condition. The nurse understands that this conversation may potentially violate which ethical principle? A. Beneficence B. Confidentiality C. Autonomy D. Veracity

Choices A, B, D, and E are correct. When supervising a UAP, the nurse should intervene if the UAP is flexing and extending the client's elbow, as that is not an active range of motion. The UAP doing the exercise for the client would be considered a passive range of motion. The UAP starting the orthostatic vital signs with the client standing is inappropriate. When obtaining orthostatic blood pressure, the correct sequence is supine, sitting, and standing. During the orthostatic vitals, the observer looks for a drop in blood pressure when the client stands up from a lying or sitting position. Neuropathy is a common manifestation in diabetic clients. Loss of sensation in the feet resulting from diabetic neuropathy may impair the client's ability to remove the feet despite the heat damage. A client with diabetes mellitus should not have feet soaked in hot water, which could impair their skin integrity and cause ulcerati

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply. - While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. - Obtains orthostatic blood pressure by having the client stand first. - Places the cane on the unaffected side of a client who had a stroke. - Provides a hot foot soak for a client with diabetes mellitus. - Obtains a urine culture from an indwelling urinary catheter.

Choice B is correct. Admission status is essential information provided in the hand-off report because involuntary admission requires the client to stay in the healthcare facility. This status is typically required when a client may pose a threat to themselves or others. This type of involuntary admission status also may raise the risk of the patient eloping. This should be communicated because if a client is involuntarily admitted, they may not have a rational thought process which may raise the risk of self-injury if they do successfully elope.

The nurse is performing a verbal hand-off report for a client. Which essential information should the nurse include in the report? A. Current medication list B. Involuntary admission status C. Food and mealtime preferences D. The presence of family at the bedside

Choices A, C, D, and E are correct. The start of the interview should begin with the nurse utilizing the client's preferred name or pronoun. This immediately conveys a caring attitude. Transgender individuals experience an incongruence between the gender they identify with and their natal sex. Negative attitudes towards transgender clients often result in the client feeling disrespected, ultimately creating hesitancy in seeking medical care. It is appropriate to inquire about any current or future plans for hormone therapy as the client may pursue surgical and non-surgical options.

The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply. - At the start of the interview, inquire about the client's preferred pronoun. - Utilize binary gender terms on healthcare documentation. - Transgender individuals feel a variance between gender and natal sex. - Clients who are transgender may be reluctant to seek healthcare. - Inquire about any current or future plans for hormone therapy.

Choice D is correct. An automatic external defibrillator (AED) should be requested immediately upon establishing that the client is in cardiac arrest. Waiting to request an AED could result in the delay of life-saving care.

The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse? A. Assesses the client's pulse by palpating the carotid artery. B. Allows for chest recoil after every chest compression. C. Compresses at a depth of 2 inches on the center breastbone. D. Asks for an automatic external defibrillator after one cycle of CPR.

Choice C is correct. Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services.

The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services? A. A client newly diagnosed with skin cancer that lives with family. B. A client recovering from a stroke and is discharged to inpatient rehab. C. A client who is homeless and has a substance use disorder. D. A client leaving against medical advice for the treatment of cellulitis.

Choice B is correct. An RN may delegate certain responsibilities to an LPN but cannot delegate accountability. The RN retains accountability when delegating patient assignments and tasks but maintains accountability.

The nurse is reviewing leadership and management concepts with a student nurse. It would require further teaching if the student nurse made which of the following statements? A. "The Laissez-faire leadership style is a passive leadership approach." B. "A Registered Nurse (RN) may delegate accountability to a Licensed Practical Nurse (LPN)." C. "The rights of delegation include task, circumstance, person, direction, supervision." D. "The State Nurse Practice Act defines roles and responsibilities of nursing professionals."

Choice B is correct. A 12-lead electrocardiogram (ECG) is essential for a client with chest pain. This test will help determine if the client has an acute myocardial infarction by showing ST elevations. In suspected acute myocardial infarction (MI), guidelines recommend obtaining an ECG within 10 minutes of the client's arrival in the emergency room. If the client is experiencing an ST-elevation myocardial infarction (STEMI), a delay in obtaining a diagnosis and/or therapeutic intervention can lead to poor clinical outcomes (increased morbidity and mortality).

The nurse is reviewing tasks for assigned clients. Which action is a priority to implement? A. Visual acuity test for a client reporting blurred vision in one eye. B. 12-lead electrocardiogram for a client reporting chest pain. C. Orthostatic vital signs for a client complaining of syncope. D. Discharge teaching for a client newly diagnosed with hypertension.

Choice C is correct. Physical needs always prioritize over other needs. For the client with anorexia nervosa, the priority is to stabilize and increase the client's weight. Anorexia nervosa may lead to life-threatening electrolyte disturbances if it goes untreated.

The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is A. attending scheduled group therapy. B. adhere to the medication regimen. C. gain one pound (half a kilogram) a week. D. demonstrate increased self-esteem.

Choice A is correct. If the nurse makes an error in written documentation, the nurse should strike out the erroneous documentation, date, time, and initial the error. Finally, the nurse should put the word 'error' near the documentation, not over the erroneous text.

The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply. - drawing a line through the erroneous documentation. - using correction tape and write over the error. - writing over the error in darker ink. - completely black out the error with a black marker. - discarding the documentation in the trash and starting over. - writing your initials, date, and time above the erroneous documentation with the word' error.'

Choices A, B, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. Incident reporting may be completed for visitors. Events that warrant reporting would include the refusal to wear PPE, tampering with medical devices (such as adjusting an infusion pump), and reporting that they fell while using the bathroom.

The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor Select all that apply. - refusing to wear personal protective equipment (PPE). - adjusting a client's infusion pump. - requesting that their family member get pain medication. - assisting their family member with brushing their teeth. - stating that they fell while using the bathroom.

Choice B is correct. The primary purpose of referrals is to ensure the completeness and appropriateness of the client's care. A registered nurse completes a referral to ensure that an appropriate individual or discipline meets the client's needs. For example, a client with a pressure ulcer or new ostomy is referred by the registered nurse to a wound/ostomy nurse for specialized treatment and counseling.

The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements describes the purpose of referrals? A. Allows the nurse to demonstrate their leadership abilities B. Care is appropriately routed to an individual or discipline C. Ensures that care is unilateral and cost effective D. Focuses on empowering the client's decision making

Choice C is correct. Because of their compromised circulation, this client would be red-tagged using the emergency triage tagging system (red, yellow, green, and black). Red tags require emergent care because of an immediate threat to their life. This client has a crushed leg with no distal sensation or pulse, significantly threatening their circulation. Thus, this client is prioritized for immediate evacuation to the nearest trauma center as a red tag.

The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation. B. has profuse bleeding from a chest laceration and is experiencing apnea. C. has a crushed leg reporting no sensation and has no distal pulse. D. is experiencing severe anxiety and has abrasions on both arms.

Choice C is correct. Blurred vision usually occurs with advanced lithium toxicity (levels between 2.0 to 2.5 mEq/L). This client's situation requires immediate follow-up because death may occur if this level of toxicity is not promptly treated. The maintenance level of lithium is 0.6-1.2 mEq/L.

The nurse is triaging phone calls at a clinic for a group of clients. Which client situation requires immediate notification to the primary healthcare provider (PHCP)? A client who A. reports a strong metallic-like taste while taking newly prescribed metronidazole. B. reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim. C. takes prescribed lithium and reports blurred vision. D. feels restless and reports difficulty sleeping while taking prescribed prednisone.

Choice B is correct. Tamoxifen is a hormone antagonist. Specifically, it is an estrogen antagonist that prevents hormone receptor-positive breast cancer. For an unclear reason, Tamoxifen increases the likelihood of adverse clotting events such as deep vein thrombosis (DVT) and venous thromboembolism or pulmonary embolism (PE). If DVT is not quickly diagnosed and treated, the client may develop a PE that can be life-threatening. A client taking Tamoxifen who experiences manifestations of DVT (leg pain, edema) or PE (dyspnea, chest pain) should promptly report these symptoms.

The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports A. decreased libido while receiving prescribed dutasteride. B. swelling in their right leg while receiving prescribed tamoxifen. C. hot flashes and night sweats while receiving prescribed letrozole. D. bone pain while receiving prescribed filgrastim.

Choice D is correct. The nurse manager needs to intervene immediately because a nurse suspected to be impaired should not supervise a newly graduated nurse or provide client care. This is a serious safety issue that the nurse manager needs to address immediately.

The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who A. falsified their documentation on a client discharged within the last 24 hours. B. needs assistance completing an incident report about a medication error on the previous shift. C. was thirty minutes late to their scheduled shift and is not wearing the correct uniform. D. is suspected to be impaired with alcohol and is precepting a newly hired nurse.

Choice C is correct. Reminding, reinforcing, and validating teaching is not within the scope of a UAP. If teaching needs to be reinforced, the nurse manager should assign this task to the licensed practical/vocational nurse (LPN/VN). As the LPN/VN may validate and reinforce teaching.

The nurse manager reviews tasks delegated to unlicensed assistive personnel (UAP). Which of the following tasks requires follow-up by the nurse manager? A. providing perineal care to a client with an indwelling urinary catheter B. performing range of motion activities C. reminding the client how to care for their long-term colostomy D. ambulating a client who requires a gait belt

Choice A is correct. Ignoring call lights (or not responding in a timely manner) puts patients at increased risk of falls and injury. The chain of command says the nurse should address issues/conflicts with the peer (if another nurse) or subordinate (UAP), as long as the situation is not illegal or dangerous. This nurse should first address issues with the UAP to determine the reason for this behavior (i.e. negligence versus work overload) and collaborate to find a solution. If the interaction is not effective, the nurse would then bring the issue up the chain of command (charge nurse) to determine the next steps.

The nurse notices a unlicensed assistive personnel (UAP) passing by several call lights during the shift. What is the nurse's best initial action? A. Approach the UAP about the behavior. B. Report unsafe behavior to the charge nurse. C. File an incident report due to safety risk. D. Ask another UAP to help cover this UAP's patient load

Choice B is correct. The nurse is concerned about the client's neurological status because of the risk of falling, causing the client an injury. The client is an older adult, and the falls for older adults are much higher than others. Additionally, the client not requesting assistance before getting out of bed is concerning because getting out of bed unsupervised may cause a preventable fall. This information is a priority to communicate because the biggest contributor to falls in the acute care environment is poor staff communication. Communicating the client's neurological status in relation to the client's risk for falling is an essential part of the nurses' responsibility for safety and risk reduction.

The nurse performs a handoff report to the oncoming nurse for an older adult male in the intensive care unit (ICU). Which information is a priority to share with the oncoming nurse? The client A. has clear lung fields bilaterally with unlabored respirations. B. is forgetful and was not requesting assistance before getting out of bed. C. has a 20-gauge peripheral vascular access device that is patent and saline locked. D. has an indwelling urinary catheter that is patent with clear urine and is secured to the upper thigh.

Choice A is correct. VRE requires a client to be placed on contact precautions. A UAP may assist the nurse in implementing transmission-based precautions, such as placing gowns and gloves outside the client's room. Gown and gloves are required for contact precautions.

The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Place gown and gloves outside of the client's room B. Educate the client and family members on ways to prevent transmission of VRE C. Affix a droplet precautions sign on the client's door D. Validate the client's understanding on hand hygiene

Choice B is correct. A suprapubic catheter should be looped and taped to the client's abdomen. Taping it to the abdomen decreases the tension on the tubing, decreasing its risk of dislodging.

The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following? A. Humidifies nasal cannula oxygen for a client with sarcoidosis. B. Secures a suprapubic catheter tubing to a client's inner thigh. C. Places a client with varicella-zoster in airborne and contact isolation. D. Suctions a tracheostomy for 10 seconds as they remove the catheter.

Choice A is correct. This finding requires follow-up because flank pain when a client has a nephrostomy tube would suggest pyelonephritis, a serious infection. Common findings associated with pyelonephritis include cloudy urine, nausea, fever, and malaise. This infection must be treated promptly because it can lead to urosepsis.

The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting A. bilateral flank pain who has two nephrostomy tubes. B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD). C. facial edema while being treated for nephrotic syndrome. D. a localized rash following the administration of ciprofloxacin for cystitis.

Choices A, C, D, and E are correct. Under HIPAA rules, healthcare agencies and their employees must take steps to ensure the confidentiality of patient information and medical records. Nurses and other healthcare providers must protect the patient's right to privacy by not sharing patient information with unauthorized individuals. Also, HIPAA allows patients to see, make corrections to, and obtain copies of their medical records. Seeking out a person's personal information by reading his/her medical chart is a violation of HIPAA. Only individuals who are providing direct care to a client should access that client's medical record. One must have a medical power of attorney and a signed HIPAA release of information form permitting them to access information before it can be legally obtained. Nurses are responsible for keeping patients' PHI secure and protected )Choice E). If a nurse leaves PHI accessible to someone who

The nurse understands that which of these scenarios would be considered a violation of HIPAA laws? Select all that apply. - Locating a co-worker's address in her medical chart so you can surprise her with a birthday gift. - Discussing discharge plans with a patient in a multi-bed recovery room with the curtain drawn around the patient's bed. - Looking up the medical information of a friend that is not in your care but who gave you permission. - Checking on your spouse's medical record because you are listed as her power of attorney. - Leaving PHI accessible to unauthorized individuals

Choice D is correct. Immobilizing the client's leg before moving the client minimizes the risk of bleeding, edema, and pain while concurrently preventing further injury to the tissues and structures surrounding the fracture. This intervention also decreases the client's risk of developing other complications, such as fat embolism and/or shock.

The nurse witnessed a client fall in the bathroom. The client is now on the floor, never losing consciousness. The nurse briefly assesses the client, immediately suspecting the client sustained a fractured hip. Which of the following nursing interventions should the nurse initiate first? A. Assisting the client back to bed B. Notifying the client's family of the fall C. Arranging for an x-ray of the region D. Immobilizing the client's leg before moving the client

Choice B is correct. Change can be difficult in any profession. To foster a positive change, the nurse manager should have an open dialogue with the nursing staff. This enables any concerns to be addressed (and mitigated) with a professional dialogue. This also allows the nurse manager an opportunity to assess the mood of the nursing staff regarding the change.

The nursing supervisor has implemented a new assignment system for nursing staff. In order to reduce resistance to this new system, the nurse manager should A. Provide incentives to foster the change B. Allow nursing staff to discuss potential concerns C. Provide statistical support for the change D. Detail the changes in a multimedia presentation

Choice A is correct. It is appropriate for the RN to delegate to the LPN/VN the dressing change and the task of obtaining the wound culture.

The registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are caring for a client with an infected leg ulcer. Which task should the RN delegate to the LPN/VN? A. Obtain wound cultures during dressing changes B. Teach the client about high-protein food choices C. Assess the risk for further skin breakdown D. Initiate an outpatient wound care referral

Choices B and E are correct. Skills such as the insertion of an NGT are within the scope of an LPN/VN. The RN can delegate this to the LPN/VN. Further, LPN/VN's may care for a client in isolation as well as administer bronchodilators via an inhaler. Practical/vocational nurses should get the most stable patient assignment.

The registered nurse (RN) assigns client care to a licensed practical/vocational nurse (LPN/VN). Which of the following should the RN assign to the LPN? Select all that apply. - A client requiring an assessment of their current medications - A client needing a nasogastric tube (NGT) for enteral feedings - A client with an insulin pump and is unsure of how to load the insulin - A client with unstable blood pressure following adrenalectomy. - A client requiring airborne isolation and bronchodilators via an inhaler

Choice B is correct. Their scope of practice for an LPN/VN allows for data collection - not assessment (which requires analysis). This would be inappropriate to delegate to the LPN and require follow-up from the charge nurse.

The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the LPN/VN would require follow-up from the charge nurse? A. Obtaining an occult blood sample for a client with ulcerative colitis. B. Assessing a newly admitted client with chest pain. C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus. D. Providing pin care for a client with external fixation of the wrist.

Choice B is correct. Managing a nasogastric tube (NGT) is within the scope of an LPN. The other client situations lack predictability, require frequent assessments or need skills performed such as intravenous therapy that is not within the scope of an LPN.

The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client A. immediately post-operative following a thyroidectomy. B. with a paralytic ileus requiring the management of a nasogastric tube. C. receiving intravenous magnesium sulfate for status asthmaticus. D. with a hypertensive crisis requiring initiation of intravenous nicardipine.

Choice B is correct. The purpose of an incident report is to provide an objective account of an incident/occurrence, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. Subjectivity should be excluded from a report because subjectivity allows for opinions on details that may not be true (example, stating I believe the client fell because he did not follow instruction) would be inappropriate.

The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation? A. The client's explanation of the event. B. Subjective factors preceding the fall. C. Any injuries sustained as a result of the fall. D. The names of all witnesses present.

Choices B, C, E, and F are correct. In most cases, client hygiene, bed-making, ambulating patients, and helping to feed clients can be delegated to unlicensed assistive personnel (UAP). Due to the pressure to reduce health care costs and the increasing demand for nursing services amid a critical shortage of professional nurses, many employers of nurses have increased their use of UAP. UAPs are trained to function in an assistive role to the nurse in the provision of client activities as delegated by and under the supervision of the nurse.

Which of the following activities can be delegated to unlicensed assistive personnel (UAPs)? Select all that apply. Performing initial client assessments Making client beds Giving clients bed baths Administering client medications Ambulating clients Assisting clients with meals

Choices A, B, D, and F are correct. Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth. There are many definitions of critical thinking. It is a complex concept and people think about it in different ways. Any situation that requires critical thinking is likely to have more than one "right" answer. You do not need critical thinking to add 2 + 2 and come up with the solution. However, you do need critical thinking to problem-solve essential decisions. A crucial aspect of critical thinking is the process of identifying and checking your assumption. This is also a necessary part of the research process. Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth.

Which of the following are components of the definition of critical thinking? Select all that apply. Reasoned thinking Openness to alternatives Adherence to established guidelines Ability to reflect Loyalty to traditional approaches Desire to seek the truth

Choices A, C, and E are correct. Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care: Safe: Avoiding injury Useful: Avoiding overuse and underuse Patient-centered: Responding to patient preferences, needs, and values Timely: Reducing waits and delays Efficient: Avoiding waste Equitable: Providing care that does not vary in quality to all recipients

Which of the following nursing improvements follow the recommendations of the Institute of Medicine's Committee on Quality Healthcare in America? Select all that apply. - Basing patient care on continuous healing relationships - Customizing care to reflect the competencies of the staff - Using evidence-based decision making - Having a charge nurse as the source of control - Using safety as a system priority - Recognizing the need for secrecy to protect patient privacy

Choice B is correct. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing, or by a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thicker mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, the priority for nurses is to evaluate the patient's status first.

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator.

Choice D is correct. After viewing documentation entered by an unlicensed assistive personnel (UAP) stating they have shaved a client who takes warfarin daily, you would ask the UAP what type of razor was used and how the client responded. The type of razor used is an important variable, as an electric or battery-operated razor is much safer than a traditional razor blade for clients on anticoagulants (including warfarin, such as this client). If the UAP used a traditional razor blade instead of an electric or battery-operated razor, you would also ask the UAP about the client's response to the shave (e.g., whether any bleeding was observed or nicks to the skin occurred, etc.). Following this discussion, you would also ask the UAP to document the type of razor used and the client's response(s) to the shave. Additionally, as the licensed health care provider and the client's nurse, you would assess the client in perso

You are observing and supervising an unlicensed assistive personnel (UAP) to determine their competency in providing personal care and hygiene for clients. Upon review of the UAP's documentation, you notice the UAP has documented shaving a client who takes warfarin daily. How should you respond? A. Tell the unlicensed assistive personnel (UAP) that shaving clients taking warfarin is prohibited. B. Complete an incident report because shaving clients is outside the assigned duties for unlicensed assistive personnel (UAP). C. Tell the unlicensed assistive personnel (UAP) to cross off the documented evidence of shaving the client. D. Ask the unlicensed assistive personnel (UAP) what type of razor was used and how the client responded.

Choice B is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It's important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented. Know these definitions: Near miss: A near miss is defined as "any event that could have had adverse consequences but did not and was indistinguishable from fully-fledged adverse events in all but outcome." In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck. In the above question, the clients have not undergone the wrong surgery and therefore, it's a near miss. Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury. These e

You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a "wrong surgery" because this possible error was caught in time. What is your priority action as the nurse manager? A. Praise the staff for catching these near misses before a surgical error occurs. B. Investigate and explore this near miss. C. Investigate and explore this medical error. D. Report the nature and frequency of these medical errors to the State Department of Health.

Choice A is correct. The most appropriate nursing diagnosis for this client is based on the refusal of medications. "The lack of adherence to the medication regimen related to the use of a psychological defense mechanism," fits the best for this client's statement. This client uses denial as a psychological or ego defense mechanism to protect against the stressors associated with the diagnosis of HIV/AIDS.

Your client has just been diagnosed with HIV/AIDS. The client is refusing their HIV/AIDS medications and is stating, "I do not have HIV/AIDS, and the laboratory has made a serious error." Which of these nursing diagnoses is the most appropriate for this client, based on this refusal of medications and this client's statement? A. The lack of adherence to the medication regimen is related to the use of a psychological defense mechanism. B. Ineffective coping is related to a laboratory error. C. Knowledge deficit related to the need for HIV/AIDS medication. D. The lack of compliance with the medication regimen is related to a knowledge deficit and laboratory errors.