LEADERSHIP Q8 ( LUZ 1.1 )
A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? "I will have to be admitted to a long-term care facility in order to receive hospice care." "I should expect the hospice team to help me manage my dyspnea." "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
"I should expect the hospice team to help me manage my dyspnea." Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.
A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse? "Let's talk about something else." "Whether or not I am a good lover is irrelevant." "Speaking to me like that makes me uncomfortable." "You need to lower your voice. Others can hear you."
"Speaking to me like that makes me uncomfortable." This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.
A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate? "Tell me why you feel hopeless." "I am sure these feelings will pass once you go home." "If I were you, I would ask for a referral to hospice care." "Tell me what you understand about your illness."
"Tell me what you understand about your illness." The nurse should use this statement to encourage the client to express her feelings and concerns.
A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients? A child who is experiencing sickle cell crisis A child who has streptococcal pharyngitis A child who has a head injury A child who has a new diagnosis of type 1 diabetes mellitus
A child who has a new diagnosis of type 1 diabetes mellitus The nurse should place these clients together. It is appropriate because the child who has diabetes requires monitoring and teaching and the child who is postoperative from an appendectomy requires frequent assessments and interventions.
A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? A client who is a 1 day postpartum after a late term miscarriage A client who had a bilateral tubal ligation 12 hr previously A client who is 4 days postpartum and has mastitis A client admitted 1 hr ago for an ectopic pregnancy
A client admitted 1 hr ago for an ectopic pregnancy A client who has an ectopic pregnancy is unstable. The client is at risk for rupture of the fallopian tube, hemorrhage, and shock. Nursing care requires frequent monitoring every 15 min, IV access for fluid resuscitation. The client may also require blood transfusions, oxygen, and pain management. Therefore this client is the highest priority.
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? The nurse identifies a broken piece of equipment. A staff member does not show up to work her assigned shift. A client discovers that his dentures are missing. The nurse has a disagreement with the nursing supervisor about inadequate staffing.
A client discovers that his dentures are missing. This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A client who has diarrhea and requests clear liquids for breakfast A client who has a cast on the left leg and reports numbness and paresthesia A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 A client who has pneumonia and has an axillary temperature of 38° C (101° F)
A client who has a cast on the left leg and reports numbness and paresthesia The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.
A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A client who has a punctured femoral artery A client who has multiple fractures A client who has a red rash over his abdomen A client who reports severe flank pain radiating to the groin
A client who has a punctured femoral artery A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged.
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight A client who has terminal cancer and needs assistance with pain management A client who is recovering from a stroke and needs someone to provide care while his spouse is at work A client who has dementia and needs help with activities of daily living
A client who has terminal cancer and needs assistance with pain management A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? An adolescent female client who is belligerent and has slurred speech A toddler who has a laceration on his forehead and is screaming A middle adult male who is diaphoretic and reports epigastric pain A young adult with a painful sunburn of his face and arms
A middle adult male who is diaphoretic and reports epigastric pain When using the urgent vs. nonurgent approach to client care, 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 triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough 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.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.) Ambulate an older adult client who has hypertension. Provide discharge instructions for a client who has a new skin graft. Perform an admission assessment on a client. Check a blood product with another nurse prior to administration. Weigh a client who has heart failure.
Ambulate an older adult client who has hypertension is correct. An AP can ambulate an older adult client who has hypertension. Weighing a client who has heart failure is correct. An AP can weigh a client who is stable.
A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? Taking a telephone prescription about a client who is to be transferred from PACU Assessing a client who experiences unilateral calf pain when ambulating Reinforcing a client's dressing for the surgical site of an above-the-knee amputation Reassuring the partner of a client who sustained a closed head injury
Assessing a client who experiences unilateral calf pain when ambulating When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is assessing a client who has manifestations of a deep vein thrombosis, which can lead to pulmonary embolus. The nurse should assess this client and report the findings immediately to the provider.
A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform? Administration of an enema Application of antiembolic stockings Assessing a client's sacrum for edema Assisting a client to cough and deep breathe
Assessing a client's sacrum for edema Assessment requires the nurse's specialized knowledge and cannot be delegated to an AP.
A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? Assigning two assistive personnel (AP) to ambulate all clients Assigning a new graduate nurse to perform a wet-to-dry dressing change Assigning the most efficient AP to perform glucometer monitoring for each client Assigning the most competent RN to perform a central line dressing change
Assigning the most efficient AP to perform glucometer monitoring for each client Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.
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? Provide a written procedure for the use of the device for the staff to review. Demonstrate using the device and observe the staff returning the demonstration. Remind the staff to review the procedure manual prior to using the new pump. Identify the differences and new features of the device in a written brochure.
Demonstrate using the device and observe the staff returning the demonstration. 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 caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? Ensuring the charge nurse is available to witness the client's signature on the consent form Explaining the risks involved with the procedure Discussing alternate treatment options Determining the client's level of understanding about the procedure
Determining the client's level of understanding about the procedure In the role of client advocate, the nurse is responsible for ensuring the client understands the information provided by the surgeon and must notify the surgeon if the client has questions.
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? Assessing the current health status of the client Explaining the operative procedure, risks, and benefits Reviewing preoperative laboratory test results Ensuring that a signed surgical consent form was completed
Explaining the operative procedure, risks, and benefits 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 in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? Invoking implied consent Delaying the surgery until a member of the client's family is reached Asking the client to sign the surgical consent form Prescribing naloxone to reverse the effects of the morphine
Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.
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 a client Allowing a new mother to hold her stillborn infant Confirming that a client going for surgery has signed a consent form Refusing to disclose information about a client to the media
Keeping an appointment with a client 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? Utilitarianism Nonmaleficence Fidelity Veracity
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 is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? Utility Paternalism Justice Nonmaleficence
Nonmaleficence The nurse is obligated to protect the client's confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client.
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? Counsel the provider to determine the cause of the substance abuse. Encourage clients to change to a different provider. Inform the state medical board for an immediate investigation. Notify the nursing supervisor of the concerns.
Notify the nursing supervisor of the concerns. The nurse should notify 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.
A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form? Extended family Blended family Nuclear family Intergenerational family
Nuclear family A nuclear family consists of parents and offspring.
A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take? Pull the curtain around the client's bed. Wash the client's arms and hands first. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus. Fill the bath basin with tap water that is 39° C (102.2° F).
Pull the curtain around the client's bed. The nurse should close the door to the client's room and pull the curtain around the client's bed to ensure the client's right to privacy.
A nurse in 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? Availability of resources, such as fire extinguishers Nursing staff ratios Quality of nursing care provided Length of facility stay for a cohort of clients
Quality of nursing care provided 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 charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change? Assess the problem. Use tactics to alert staff nurses that a change is needed. Evaluate the effectiveness of the change. Set a target date.
Set a target date. During the moving stage, the charge nurse should develop the plan for change and set the target date.
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? The client who requires frequent ambulation The client who is in protective isolation The client who is actively dying and requires IV pain medication The client who is 3 days postoperative and requires a dressing change
The client who is actively dying and requires IV pain medication The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? The nurse uses clean gloves when discontinuing a client's intravenous infusion. The nurse empties a client's drainable colostomy pouch when it is one-third full. The nurse uses the client's telephone number as one form of identification when administering medications to a client. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. The nurse should avoid reaching across a sterile field; therefore, the nurse should place the sterile tray on the work surface so the top flap opens away from the body.
A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN? The state Nurse Practice Act The National Association for Practical Nurse Education and Services The National Council of State Boards of Nursing Decision Tree The Omnibus Budget Reconciliation Act of 1987
The state Nurse Practice Act The state Nurse Practice Act identifies the skill or education level needed by a nurse to complete a task, as well as indicating items that can and cannot be delegated from a legal perspective.
A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? Preventing cross-contamination of clients Performing concise client assessment Transferring a client to the discharge location Maintaining a client tracking system
Transferring a client to the discharge location Nursing care in a disaster setting focuses on essential care. The nurse should recognize nonskilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel.
A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.) Establish that the client is able to pay for the surgical procedure. Explain the surgical procedure to the client. Validate the signature is authentic. Verify the client understands the surgical procedure. Confirm that the consent is voluntary.
Validate the signature is authentic is correct. The nurse must validate the signature on the consent is made by the client or the client's legal guardian. Verify that the client understands the surgical procedure is correct. The nurse should verify the client understands the procedure and the risks. Confirm that the consent is voluntary is correct. The nurse should confirm the client is giving voluntary consent without coercion.
A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching? "Disaster drills should be held on a regular basis." "An actual disaster cannot take the place of a disaster drill." "A staff nurse can function as the incident commander." "A physician must triage victims of a disaster in the emergency department."
"Disaster drills should be held on a regular basis." Hospitals should perform disaster drills on a routine basis to ensure effective response in the event of a disaster.
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? "I have my assignment and will start with room 1, then work my way to room 10." "I will give this client his meal tray first, as he is going early to physical therapy." "After breakfast, I will pack the belongings of clients who will be discharged this morning." "I will start by providing partial baths before breakfast."
"I have my assignment and will start with room 1, then work my way to room 10." The AP's statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized.
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 An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax A middle adult who is 36 hr postoperative from an open laminectomy An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32
A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy 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 nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict? Nurses on the unit disagree about what time of day daily client weights should be obtained A nurse is uncertain about joining a professional nursing organization A nurse who just lost his spouse does not want to be assigned to care for a terminally ill client An experienced nurse is uncivil to a newly licensed nurse
An experienced nurse is uncivil to a newly licensed nurse Incivility and bullying are examples of interpersonal conflict. Interpersonal conflict arises from differing goals and value systems.
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 assess first? A school-age child who has diabetes mellitus and requires blood glucose monitoring An infant who has pertussis and is receiving oxygen via nasal cannula An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions A toddler who has both arms in casts and needs to be fed his breakfast
An infant who has pertussis and is receiving oxygen via nasal cannula Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.
A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first? Notify hospital security. Approach the man and ask why he is making copies. Inform the nursing supervisor. Report the observation to the nurse caring for that client.
Approach the man and ask why he is making copies. The first action the nurse should take using the nursing process is to assess the situation to determine whether this man is authorized to be in possession of the client's medical record to protect the client's confidentiality. Making copies from a client's medical record is allowed under specific circumstances. It is important to act in a timely fashion to protect the client's medical information. The nurse should approach the individual in a nonthreatening way to inquire about the copies being made.
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (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. Seek immediate help from the risk manager. Call the provider for a stat DNR order. Respect the family's wishes and do nothing.
Call the emergency response team. 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 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? Determines the client does not have a mental illness Confirms the client appears competent to provide consent Asserts the nurse has explained the risks and benefits of the procedure Records that the client's spouse agrees the procedure is necessary
Confirms the client appears competent to provide consent 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.
