LEADERSHIP FINAL ATI

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

"Delegation permits a designated individual to meet a goal on your behalf." Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate?

"Let's talk about your concerns about the new policy." Rationale: The nurse manager should meet with the nurse to allow an open forum for the nurse to verbalize the reasons for her reluctance to adopt the new policy.

A coworker puts an arm around the nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?

"Speaking to me like that makes me uncomfortable." Rationale: This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

"The client was found unconscious on the floor in her home." Rationale: This statement is the background or context of the situation, which is the B step in the SBAR tool. The background portion should provide information that is pertinent to the current situation.

A nurse manager is providing an inservice program about delegation to assistive personnel with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

"The nurse should consider the AP's level of experience when making delegation decisions." Rationale: When delegating a task, the nurse should delegate the task to the right person. The nurse should consider the AP's job description, level of knowledge, and individual level of experience.

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? Select all that apply.

1. Check on the client hourly. 2.Instruct the client in the use of the call light. 3.Apply an ambulation alarm on the client's leg. Rationale: Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are in reach. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. The ambulation alarm signals when the client's leg is in dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel for which of the following clients?

A client who is 3 days postoperative following gastric bypass surgery. Rationale: The client's physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. The client is 3 days postoperative and his condition would have stabilized by this time.

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?

A middle adult male who is diaphoretic and reports epigastric pain. Rationale: The nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction.

A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?

A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. Rationale: Professional negligence is performing practice below the expected standard of care. It can be an act of omission, which is the failure to perform an act that a reasonable prudent person, under similar circumstances, would do. A reasonable prudent nurse would notify the provider of the neuromuscular finding immediately.

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?

A school-age child who has acute epiglottis, is drooling, and has an absence of spontaneous cough Rationale: The client is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy Rationale: A client who is scheduled for an elective surgery is medically stable and is not bedridden; therefore, the nurse should recommend this client for discharge.

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?

Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. Rationale: The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?

Ask what she will be assigned to do. Rationale: Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative O2 level is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of SBAR report?

Assessment Rationale: The nurse should include his assessments in this level of the report.

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?

Battery Rationale: Battery is physical contact without the client's consent. Administering a medication against a client's wishes is an example of battery.

A nurse enters a client's room and finds the client pulseless. The family requested a DNR order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Call the emergency response team. Rationale: Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "the doctor didn't tell me I was supposed to receive an enema". Which of the following actions is appropriate at this time?

Check the client's medical record for the provider's prescription. Rationale: The nurse should use the client's medical record to verify the provider prescribed an enema for the client.

A nurse on an quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the charges?

Compare the number of medication errors before and after the action was implemented. Rationale: Preimplementation and post implementation statistics for medication errors will provide information to determine the success of the actions.

A nurse caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following?

Confirms the client appears competent to provide consent Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent.

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly?

Demonstrate using the device and observe the staff returning the demonstration. Rationale: The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.

A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?

Encourage the client to verbalize questions. Rationale: The nurse acts as a client advocate by providing the client with information needed to make informed decisions regarding care.

A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?

Explain the risk the client faces if she leaves the facility. Rationale: The expected reference range INR while a client is taking warfarin is 2-3. The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Explaining the operative procedure, risks, and benefits Rationale: Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility.

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

Keeping an appointment with the client Rationale: Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?

Nonmaleficence Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?

Notify the nursing supervisor of the concerns. Rationale: The nurse should notify the hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse.

An assistive personnel reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Obtain vital signs. Rationale: Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

Platelet count of 60,000 Rationale: This platelet count is below expected range.

A nurse is an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?

Quality of nursing care provided Rationale: Process audits evaluate the quality of care nurses provide. They also determine if the care provided by nurses is consistent with established facility policy.

A nurse overhears two assistive personnel from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?

Quietly tell the APs that this is not appropriate Rationale: The nurse has a professional duty to protect the client's confidential information. The nurse determines the priority is to stop the Ads before there is an additional breach of confidentiality.

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel?

Random stool specimen Rationale: The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if the culture using a sterile swab is required.

A nurse is serving on a continuous quality improvement committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Review the events leading up to each medication administration error. Rationale: After a sentinel event, the first step the committee should plan to take is to use root cause analysis to identify the underlying cause or causes that led to the medication errors.

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement?

Sit in front of the group for the meeting and then stand for the announcement Rationale: The weight of the message increases when the sender stands.

A nurse caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?

Submit the incident report to the risk manager. The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.

When planning delegation of tasks to assistive personnel, a nurse considers the five right of delegation. Which of the following should the nurse consider when nursing one of the five rights of delegation?

The AP has the knowledge and skill to perform the task Rationale: The right person is one of the five rights of delegation. The nurse should seek information from the AP about their individual skill level before delegating the task.

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

The nurse separates the client's labia with her dominant hand. Rationale: The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon.

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information?

The purpose of medication reconciliation is to prevent adverse medication reactions. Rationale: Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes.

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?

Withholding a dose of narcotic pain medication when the client has respiratory depression Rationale: Nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence.