Leadership Exam 1

a nurse may assign the AP to collect vital signs on which of the following clients? SATA

- a client who has a history of congestive heart failure. - a young adult client who is 1 day post operative following an appendectomy - a client who is 2 days postoperative following a laparoscopic cholecystectomy

a nurse is planning to assign care activities to the assistive personnel. which of the following activities are appropriate for assignment to the AP? Select All That Apply

- accompanying a client with depression to occupational therapy - checking the position of a client in soft wrist restraints - sitting with a client who abuses alcohol whose last drink was two days ago

a nurse is caring for a group of clients on a medical surgical unit. which of the following actions jeopardizes client confidentiality? SATA

- discussing clients at the table in the cafeteria - giving a verbal report at change of shift outside clients room is correct - disposing of written report sheet into the hospital trash receptacle

a client expresses interest in learning more about advance directives. which of the following topics should the nurse anticipate discussing? SATA

- enteral feeding tubes - cardiopulmonary resuscitation - durable power of attorney for health care

a nurse is assisting with the discharge plan of a client who has a permanent tracheostomy. the nurse should verify the availability of which of the following equipment? SATA

- oxygen - suction machine - replacement cannula

a nurse applies wrist restraint to a client who is confused and attempting to pull out a chest tube, which of the following would be an appropriate action?

Document client action that necessitated the restraints

a nurse has assigned client care activities to assistive personnel? which statement by the AP indicates a need for assistance in establishing priorities?

I have my assignment and will start with room 1, then work my way to room 10

a nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. which of the following tasks should the nurse assign in the assistive personnel AP?

Monitoring vistal signs of a client who had an appendectomy 12 hours ago

a nurse is working with the AP and reviewing the list of tasks that have been delegated to the AP by the charge nurse. which of the following tasks requires clarification?

Removing and cleaning the cannula of a client with a new tracheostomy

a nurse on a pediatric unit is notified that a child is being admitted following an appendectomy and is to be placed in a room with another client. the nurse should plan to place the child with which of the following clients?

a child with type 1 diabetes

a nurse is assigned a group of clients at the start of the shift. which of the following clients should the nurse plan to see first?

a client asking about his PCA pump which contains morphine

a nurse is listening to report on assigned clients at the beginning of the shift. which of the following information established a priority for the nurse?

a client had a catheter removed 7 hr ago and has not voided

a nurse is working at a health care facility in which there is a threat of flooding, and an internal disaster plan has been activated. which of the following clients should the nurse evacuate first?

a client receiving antibiotic IV therapy and wound vacuum care

a charge nurse is delegating meal assistance after delivery of the dinner trays. the nurse should delegate meal assistance for which of the following clients to the AP?

a client who has Parkison's disease

a nurse is planning to assign obtaining the vital signs of postoperative clients to an AP. The nurse should assign obtaining vital signs for which of the following clients?

a client who is 3 days postoperative following gastric bypass surgery.

the registered nurse is preparing assignments for the day shift. which of the following clients should the nurse plan to assign to the licensed practical nurse?

a client who is two days postoperative following a hip replacement

a licensed practical nurse is receiving change of shift report. which of the following clients should cause the nurse to request a change of assignment?

a client who will be started on total parenteral nutrition during the current shift.

a nurse is assigned four post operative clients. which of the following clients should the nurse address first?

a client whose blood pressure at 0800 was 138/86 mm hg and at 1200 is 106/60 mm hg

a nurse manager is reviewing safe delegation practices with nurses on the unit, which of the following is an appropriate statement by the nurse manager?

all delegated tasks require follow up to ensure compliance.

a nurse on a pediatric unit is reviewing her client assignment following the shift report. which of the following clients should the nurse plan to see first?

an infant with pertussis receiving oxygen via nasal cannula.

a nurse is organizing care for a group of clients. which of the following tasks could the nurse assign to the AP?

assist a client who is 1 day postoperative following an appendectomy requesting a bedpan

a nurse is planning care for a client who has anorexia nervosa. which of the following client goals has the highest priority? the client will?

attain a weight that is greater than 75th percentile for age and height.

a nurse is planning to use an SBAR communication tool when calling a provider. which of the following statements by the nurse is appropriate for the "B" step in this tool?

client was found unconscious on the floor in her home

a nursing is caring for a client who requires catheterization for a urine specimen. the client tells the nurse that she is concerned about her privacy during the procedure. which of the following actions should the nurse take to alleviate the client's concern?

close the door and assure the client that she will be covered.

a nurse is collaborating on care for a client following a cerebrovascular accident. which of the following should addressed by an occupational therapist?

completing selfcare

a nurse should recognize that which of the following clients would most benefit from an interdisciplinary client care conference? a client who is admitted with a diagnosis of

cystic fibrosis

a nurse is orienting a group of a new graduate nurses and explain the purpose of delegation. which of the following in an appropriate statement by the nurse?

delegation permits a designated individual to meet a goal on your behalf

a nurse asks the AP to take a specimen to the laboratory and the AP refuses. which of the following actions should the nurse take?

discuss the incident with the AP

a severe storm resulted in an RN working with one assistive personnel AP on a medical surgical unit. after talking with the hospital incident commander, which of the following actions by the nurse is appropriate.

focus on providing care that prevents life threatening emergencies.

a nurse is caring for a client who is semi-comatose, and the client's son reports that the family does not want any heroic gesture performed. How should the nurse respond?

i will verify the status of the advance directives

a nurse working on a surgical unit receive a phone call from a clients neighbor who requests a postoperative update. how should the nurse respond?

inform the neighbor that you cannot give out any information about the client

a nurse is caring for a client whose informed consent has been signed in preparation for a procedure. the client states, "i have decided not to have the procedure" which of the following actions should the nurse take?

inform the provider that the client is withdrawing consent.

a nurse is performing cpr on an adult who has suffered cardiac arrest at the grocery store. the nurse understands that the good Samaritan law civil immunity if the nurse

is certified in cpr and basic life support

a nurse is caring for a client undergoing hemodialysis who will be discharged in the morning. which of the following client statements most influences the current plan of care?

my neighbor who takes me everywhere wrecked the car this morning

a newly licensed nurse is planning to delegate tasks to an AP. which of the following tasks should the nurse plan to perform?

observing a client's sacrum for edema

which of the following tasks could a nurse assign to assistive personnel?

obtaining viral signs on client who are stable.

an AP reports that the nurse that a client who returned to the unit following abdominal hysterectomy has a dressing which is saturated with blood, which of the following tasks should be delegated to the AP?

obtaining vital signs

a nurse has received a change of shift report and is delegating tasks to the assistive personnel AP. the nurse should tell the AP to perform which of the following?

perform blood glucose monitoring of a client who has a prescription for short acting insulin prior to breakfast

a nurse is caring for a client who is diagnosed with cerebrovascular accident CVA/STROKE. which of the following actions should be implemented to prevent deep vein thrombosis DVT

place sequential compression devices bilaterally

a nurse is caring for a client who does not speak English. how should the nurse reinforce teaching regarding a colonoscopy?

provide a hospital assigned interpreter to relay medical information.

a nurse is obtaining blood samples for type and crossmatch from two clients both scheduled for minor surgical procedures in the morning. later in the shift, the nurse becomes convinced that the labels on the specimens were inadvertently switched. due to the nature of the procedures, the nurse realized that neither client is likely to require transfusion. what is the appropriate action for the nurse to take at this time?

redraw both specimens, label them carefully and inform the blood bank of the error.

a nurse is caring for a client who is confused and combative and requires placement in jacket and wrist restraints. to prevent injury to this client which of the following actions should the nurse take?

remove the restraints and observe the client's extremities for circulation every 4 hr

a nurse is providing pin site care to a client in skeletal traction. which of the following action should prompt the charge nurse to interview?

removing the crust around pin sites during cleaning

a nurse is reviewing all occurrence reports submitted during the previous month. the nurse should identify which of the following as a problem that should be reported to the risk manager.

reports routinely omit the names of witnesses to the occurrence.

a nurse is caring for a client. how should the nurse verify the client's durable power of attorney?

review paperwork completed upon admission

a charge nurse has assigned a group of clients to a newly licensed practical nurse. the charge nurse observes the LPN chatting sociably with peers. learns that the LPN left the unit without communicating the absence and receives reports from clients about lack of care by the LPN. which of the following is an appropriate action by the charge nurse?

review the LPN's assignment in relation to other nurses on the unit.

a nurse checks with the nursing personnel on the unit throughout the day to determine if they are completing tasks. the nurse is demonstrating which of the following rights of delegation?

right supervision

a licensed practical nurse is providing care to a client who has copd. which of the following findings should be reported to RN immediately?

speaks in short phrases.

a nurse is caring for a client who is experiencing dysphagia. which of the following referrals is appropriate at this time?

speech therapist

a nurse should intervene when observing an AP do which of the following with a client's medical record?

tears a document with client information in half before disposing of it in a waste basket.

the manager is reviewing the accountability for client outcomes when delegating tasks to AP with nurses on the unit. which of the following statements by a nurse is appropriate?

the AP has no accountability for client outcomes when preforming delegated tasks.

a nurse has listened to a report at the start of the shift, which of the following statements by the RN during this report indicates that the nurse should assume total care for the client, rather than assigning tasks to the assistive personnel?

the clients blood pressure and pulse have a been unstable

a nurse is reinforcing teaching to the AP to set limits on a client's manipulative behavior after the nurse has reviewed the AP's performance of a delegated task. which of the following responses by the AP indicates further teaching is needed?

the goal for the client is to ask directly for what he wants

a newly licensed nurse is planning to perform a procedure on a client that she has not done before. which of the following resources should the nurse use to help her perform the procedure?

the policy and procedure manual for the unit

a nurse is caring for a client who is pregnant and refuses to receive chemotherapy. which of the following is the best response for the nurse to give?

this must be a difficult decision for you