Leadership Test 1 oriented questions

A nurse is delegating a client care task to an assistive personnel (AP). Which of the following directions should the nurse give the AP? A. "This client needs to ambulate using a walker three times today." B. "Please record strict intake and output for this client." C. "This client needs to have blood glucose monitoring before each meal." D. "Please obtain vital signs from all the clients to whom you are assigned today.

" Correct Answer: A. "This client needs to ambulate using a walker three times today." This direction includes the type of task to be done, the frequency with which the task is to be performed, the duration of the task, and information about the mechanics of ambulating the client.

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. This nurse has limited experience with children. Which of the following actions should the nurse manager take? A. Provide constant supervision for the medical-surgical nurse. B. Have the medical-surgical nurse provide relief for unit nurses during break and lunch times. C. Assign a unit nurse to act as a resource for the medical-surgical nurse. D. Delegate assistive personnel tasks to the medical-surgical nurse. Correct

Answer: C. Assign a unit nurse to act as a resource for the medical-surgical nurse. Assigning a nurse who usually works on the pediatric unit to assist the medical-surgical nurse will provide consistent support.

A nurse is caring for a male client who is scheduled for a procedure. The client's son asks the nurse what medication is being given to the client. Which of the following responses should the nurse provide? A. "I am sorry, but you'll need to ask your father for that information." B. "Your father was given lorazepam to treat anxiety." C. "You will need to ask the charge nurse for that information." D. "Don't worry. We will give your father all pertinent information before discharge."

Correct Answer: A. "I am sorry, but you'll need to ask your father for that information."

A nurse is writing a goal for a client's reaction following the administration of a medication. This action should take place during which of the following phases of the nursing process? A. Planning B. Evaluation C. Analyzing D. Assessment

Correct Answer: A. Planning The nurse should write expected outcomes as part of the planning phase of the nursing process. During planning, the nurse establishes goals and outcomes for the client and selects the interventions that will help achieve those goals and outcomes. Planning also involves setting care priorities.

A charge nurse in an emergency department is making assignments for an assistive personnel (AP) during a shift with unexpected staff absences. Which of the following assignments should the charge give to a float AP from the medical-surgical unit? A. Escorting clients from the emergency department to other areas of the facility for tests B. Sitting at the reception desk answering telephones and directing clients C. Restocking the examination rooms after each client is discharged D. Shadowing an AP who is regularly assigned to the emergency department

correct Answer: A. Escorting clients from the emergency department to other areas of the facility for tests Clients in the emergency department often require transport to other departments. Typically, transporting stable clients is a task that may be delegated to an AP, and escorting clients is likely a normal part of the AP's regular routine.

A nurse is caring for 4 clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client? A. Cerebral arteriogram B. Magnetic resonance imaging (MRI) C. Computed tomography (CT) scan D. Carotid ultrasound Correct Answer:

A. Cerebral arteriogram A cerebral arteriogram is considered invasive because it involves injecting contrast material into an artery to study the cerebral circulation. Written consent is required.

A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. Which of the following actions should the nurse take? A. Tell the client that he will be put in restraints if he attempts to get out of bed again. B. Ask an assistive personnel to sit with the client. C. Remind the client to stay in bed. D. Restrain the client immediately to prevent self-harm

. Correct Answer: B. Ask an assistive personnel to sit with the client. This client is at risk of falling. Having an assistive personnel sit with the client protects him from harm. Then, the nurse can contact the provider to discuss care options for this client (e.g. restraints or placing an audible alarm).

A nurse is planning care for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Avoid the use of facial gestures when speaking to the client. B. Speak to the client in a loud tone of voice. C. Use child-like phrases to help the client understand commands. D. Offer pictures for the client to point to as an alternative form of communication

. Correct Answer: D. Offer pictures for the client to point to as an alternative form of communication. The nurse should use alternative forms of communication as needed with the client such as offering pictures the client can point to or a communication board.

A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first? A. A client who requires a sterile dressing change B. A client who requires gastrostomy tube feeding C. A client who requires urinary catheter care D. A client who requires endotracheal suctioning

Correct Answer: D. A client who requires endotracheal suctioning When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should attend to a client who requires endotracheal suctioning first. Without this intervention, mucus and secretions could accumulate and block the client's airway.

A home health nurse is caring for a client who asks about the purpose of a living will. Which of the following statements should the nurse include in the teaching? A. "It establishes who will make health care decisions for the client if the client is not able to do so." B. "It allows the client to express personal wishes regarding health care decisions." C. "It serves as an informed consent form for any procedure prescribed by a provider." D. "It is only valid when a client is lucid and able to make informed decisions independently."

Correct Answer: B. "It allows the client to express personal wishes regarding health care decisions." A living will allows the client to specify what aspects of care and treatment are to be accepted or refused in the event that the client can no longer communicate those decisions.

A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? (Select all that apply.) A. Obtain the morning capillary blood glucose tests B. Bathe a client scheduled for physical therapy at 0900 C. Distribute the breakfast trays D. Fill pitchers with fresh water and ice

B. Notifying the provider is correct. The nurse should notify the provider of the finding as a part of the variance reporting process. C. Completing a variance report is correct. The nurse should complete an incident or variance report regarding the occurrence.

A nurse in an emergency department is caring for 4 clients. Which of the following findings requires the nurse to act as a mandatory reporter? A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg B. A client who was admitted for pneumonia and reports having no heat or running water at home C. A client who has depression and a self-inflicted wrist laceration D. A public official who is admitted with alcohol withdrawal and delirium tremens

Correct Answer: A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg This child exhibits findings of neglect and endangerment. The nurse is a mandatory reporter for any client situation in which children or older adult clients are being abused or neglected.

A nurse is planning care for several clients. Which of the following clients should the nurse refer to a case manager? A. A client who has neurological deficits following a stroke B. A married female client who has delivered a full-term newborn C. A client who is postoperative following a cholecystectomy D. A child who has a fracture of the dominant arm

Correct Answer: A. A client who has neurological deficits following a stroke The nurse should refer this client to the case manager for care. A client who had a stroke will likely require long-term treatment. A client who has ongoing needs for care or rehabilitation should receive care that is directed by a case manager due to the complexity and cost of the client's needs.

A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first? A. Collect information related to the issue. B. Consider the possible choices of action. C. Make a decision regarding transplant recommendation. D. Justify the recommendation for or against a transplant.

Correct Answer: A. Collect information related to the issue. According to evidence-based practice, the committee should take the first step in ethical decision-making by identifying the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation.

A nurse is planning care for a group of clients. Which of the following actions should the nurse plan to take? A. Delegate the administration of an intermittent tube feeding to a licensed practical nurse (LPN) B. Assign an assistive personnel (AP) to monitor a client's dressing for evidence of bleeding C. Ask an AP to explain to a client how to empty a urinary leg bag D. Delegate the administration of a unit of packed RBCs to a client to an LPN

Correct Answer: A. Delegate the administration of an intermittent tube feeding to a licensed practical nurse (LPN) Administering a tube feeding is within the scope of practice for an LPN

A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel (UAP). Which of the following activities should the nurse manager perform first? A. Determine the learning needs of the UAPs B. Administer a skills pretest to the new UAPs C. Provide the new UAPs with a performance checklist D. Ask the UAPs about any weaknesses they may have

Correct Answer: A. Determine the learning needs of the UAPs The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, he/she must first collect adequate data. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision; therefore, the nurse manager should first determine the learning needs of the UAPs.

A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first? A. Hemothorax B. Open humeral fracture C. Multiple deep abrasions on the arms and face D. Superficial partial-thickness burns on both legs

Correct Answer: A. Hemothorax The nurse should apply the survival potential priority-setting framework in mass casualty situations, when resources are scarce and resources must be allocated to save the greatest number of lives. While it could seem that the client who is most at risk should receive priority care, this client is the lowest priority. The nurse should assign the highest priority to the client with injuries that are severe who has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receives treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization, the client is likely to survive.

A charge nurse is making daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Measuring vital signs B. Reinforcing an IV catheter dressing C. Conducting a preoperative admission assessment D. Showing a client how to use a walker

Correct Answer: A. Measuring vital signs According to the National Council of State Boards of Nursing, delegation is the transferring of authority to perform a selected nursing task in a certain situation to a competent individual. Examples of tasks a nurse can delegate to an AP are measuring and documenting vital signs, performing postmortem care, and measuring and documenting intake and output.

A nurse receives the morning change-of-shift report and delegates several tasks to an assistive personnel (AP) on the team. Which of the following tasks should the nurse instruct the AP to perform first? A. Obtain the morning capillary blood glucose tests B. Bathe a client scheduled for physical therapy at 0900 C. Distribute the breakfast trays D. Fill pitchers with fresh water and ice

Correct Answer: A. Obtain the morning capillary blood glucose tests The nurse should apply the urgent vs nonurgent priority-setting framework when delegating tasks. The nurse should prioritize urgent needs because they pose more of a threat to the client. The nurse may need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Insulin administration is dependent on the blood glucose levels; therefore, the most urgent task the AP should complete is obtaining the morning capillary blood glucose tests.

A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? A. Paralysis of a client's lower extremities occurred following epidural anesthesia. B. A client fall during ambulation did not result in client injury. C. A client's family member complained that a nurse was culturally insensitive. D. Surgery to the wrong site was stopped prior to a procedure.

Correct Answer: A. Paralysis of a client's lower extremities occurred following epidural anesthesia. An incident resulting in permanent harm, such as paralysis or death, is a sentinel event. Sentinel events are a high priority and indicate the need for an immediate investigation.

A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)? A. Perform a simple dressing change. B. Interpreting a client's blood glucose reading C. Providing advice when speaking to a client's family member on the phone D. Determining the effectiveness of a client's urinary catheter

Correct Answer: A. Perform a simple dressing change. The nurse should identify that the completion of a simple dressing change is within the AP's range of function. Therefore, the charge nurse can delegate this task to an AP. Incorrect

An RN is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to a licensed practical nurse (LPN)? A. Performing tracheostomy suctioning for a client who is stable B. Preparing an admission assessment for a client who is preoperative C. Creating a plan of care for a client who has COPD D. Interpreting a client's digoxin level

Correct Answer: A. Performing tracheostomy suctioning for a client who is stable An RN may delegate the task of performing tracheostomy suctioning for a client who is stable or whose tracheostomy is not new to the LPN. This task is within the LPN's scope of practice.the LPN's scope of practice. This involves assessment and is the

A nurse is writing a goal for a client's reaction following the administration of a medication. This action should take place during which of the following phases of the nursing process? A. Planning B. Evaluation C. Analyzing D. Assessment

Correct Answer: A. Planning The nurse should write expected outcomes as part of the planning phase of the nursing process. During planning, the nurse establishes goals and outcomes for the client and selects the interventions that will help achieve those goals and outcomes. Planning also involves setting care priorities.

A nurse is walking with a client who falls after the facility-issued walker loses a wheel. Which of the following actions should the nurse take regarding the completed incident report? A. Submit the variance report to the risk manager. B. Place the variance report in the client's chart. C. Document the completion of the incident report in the client's medical record. D. Make a copy of the variance report for the provider.

Correct Answer: A. Submit the variance report to the risk manager. Incident reports are confidential documents used by the institution to improve client care. Filing an incident report does not supersede the need for documenting the assessment in the client's medical record and notifying the provider. Once completed, the variance form should be submitted to the institution's risk manager.

A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a nonpunitive approach, which of the following actions should the nurse manager take? A. Verbally remind the employee about the facility's employment standards. B. Recommend that the employee review the facility's policy regarding absences. C. Inform the employee in writing about the facility's employment policy. D. Ask the employee for a written action plan after discussing the reasons for these absences.

Correct Answer: A. Verbally remind the employee about the facility's employment standards. Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior.

A nurse from a facility's float pool receives an assignment to float on a nursing unit. The float nurse tells the charge nurse that she has never worked on this unit before. How should the charge nurse respond? A. "I'll be sure to give you an easy assignment so you won't have any difficulty adjusting to our unit." B. "I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." C. "Don't worry about that. Come find me if you have any questions, and I will try to help." D. "I'll call the supervisor and ask if another float nurse is working who has experience with our unit."

Correct Answer: B. "I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." Providing the float nurse with a co-assigned resource person is appropriate. This resource is part of a float pool, not just a nurse floating from another unit, and it is likely that she will be assigned to this unit in the future. The charge nurse can facilitate her orientation to the unit by providing a resource person who is skilled in the care provided to clients on the unit.

A nurse is working with an assistive personnel (AP) who appears to be under the influence of alcohol during the night shift. Which of the following is the priority action for the nurse? A. Confront the AP regarding alcohol use and remove him from client care. B. Ask the nursing supervisor to observe the AP and validate these suspicions. C. Document observations made about the AP's behavior in a factual manner. D. Report the incident to the nurse manager in the morning.

Correct Answer: B. Ask the nursing supervisor to observe the AP and validate these suspicions. After gathering data, the nurse must first validate these suspicions with another observer, take the appropriate action to safeguard clients, and then document the incident

A nurse is planning care for a client following a coronary arterial bypass graft procedure. The nurse places a referral for a case manager to visit the client. Which of the following pieces of information should the nurse share with the client about the role of a case manager? A. "The case manager will provide your direct care for the remainder of your stay in the facility." B. "The case manager will coordinate and plan your care while you recover from your surgery." C. "The case manager will meet with you on the day before your scheduled discharge date." D. "The case manager is responsible for completing your insurance claim forms."

Correct Answer: B. "The case manager will coordinate and plan your care while you recover from your surgery." The role of the case manager is to coordinate and plan client care, collaborate with other health professionals, and monitor costs and quality of care.

A charge nurse is performing a quality-assurance audit on the documentation of several clients' charts. Which of the following documentation items should the charge nurse identify as a correct entry in the client's medical record? A. "The client appeared angry when family members were visiting." B. "The client ambulated for 10 min three times during the shift." C. "The client seemed to be upset about the diagnosis." D. "An incident report was completed when the client fell at 1000."

Correct Answer: B. "The client ambulated for 10 min three times during the shift." The charge nurse should identify that this documentation item reflects objective data about the client's actions.

A group of nurses on a telemetry unit informs a nurse manager of a need to update the cardiac monitoring system to improve arrhythmia detection. Which of the following responses should the nurse manager make? A. "This purchase will require the completion of a variance analysis." B. "This purchase will need to be addressed in the capital budget plan for the unit." C. "This purchase will result in a reduction in the operating budget." D. "This purchase can be reimbursed by Medicare funds, as clients who use Medicare will benefit from the equipment."

Correct Answer: B. "This purchase will need to be addressed in the capital budget plan for the unit." The capital budget involves planning for spending related to equipment and major purchases that have a long life of use.

A nurse is delegating tasks to an assistive personnel (AP) for the care of a group of clients. Which of the following directions should the nurse provide? A. "Take the temperature of the client in room 200." B. "Transport the client in room 203 to the radiology department at 1000." C. "Obtain the vital signs of the client in room 205 when he returns from surgery." D. "Contact the provider of the client in room 208 regarding her decreased hemoglobin level."

Correct Answer: B. "Transport the client in room 203 to the radiology department at 1000." This statement observes the rights of delegation. It provides an appropriate task within the AP's scope of practice and offers the right communication by telling the AP which client to transport, where to take the client, and what the time the client needs to be at the radiology department.

A charge nurse is making shift assignments for a team that includes RNs, licensed practical nurses (LPNs), and assistive personnel. Which of the following clients should the nurse assign to an LPN? A. A client who was just admitted by the unit staff for recurring angina B. A client who has emphysema and pneumonia and is receiving oxygen C. A client who has breast cancer and is receiving chemotherapy D. A client who was just admitted by the unit staff for a cerebrovascular accident

Correct Answer: B. A client who has emphysema and pneumonia and is receiving oxygen This client requires routine care, medication administration, and data collection. This is an appropriate client to assign to an LPN.

A nurse is teaching a group of newly licensed nurses about violations of client rights. Which of the following examples of a violation of client rights should the nurse include in the teaching? A. A client who is confused and recovering from abdominal trauma has mitten restraints placed to prevent disruption of an abdominal wound. B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex. C. A health care proxy releases the medical records of a client to a long-term care facility for a placement evaluation. D. The parents of a 16-year-old who has gunshot wounds decide to limit their child's visitors to family members only.

Correct Answer: B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex. Seclusion is a restraint that should be used when a client is demonstrating violent or self-destructive behavior that jeopardizes the safety of self or others. This client does not meet the criteria for seclusion

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who is to be discharged with a peripherally inserted central catheter (PICC) line B. A client who is disoriented and awaiting a transfer to a long-term care facility C. A client who is 16 hours postoperative following a total laryngectomy D. A client who is newly admitted for abdominal pain of unknown origin

Correct Answer: B. A client who is disoriented and awaiting a transfer to a long-term care facility A client who is disoriented will need observation and reality orientation, which is within the LPN's scope of practice. The client's condition can also be categorized as stable since discharge to a long-term care facility is scheduled.

A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict-resolution styles is an example of one nurse putting aside personal goals to satisfy the other nurse? A. Avoidance B. Accommodation C. Compromise D. Collaboration

Correct Answer: B. Accommodation Accommodation is when one person puts aside personal goals to satisfy the needs of another individual. This nurse is using accommodation in order to resolve the conflict.

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication? A. A 3-year-old client who has a burned foot B. An 80-year-old client who has a fractured hip C. A 30-year-old client who has a cast applied for a fractured ankle D. A 42-year-old client who has an indwelling urinary catheter

Correct Answer: B. An 80-year-old client who has a fractured hip The nurse should identify that an 80-year-old client who has a fractured hip is at the greatest risk for a complication due to immobility and a lack of lower-extremity movement, which can lead to deep-vein thrombosis (DVT). DVT is caused by venous stasis and blood clot formation in the vascular system and can lead to pulmonary emboli. The nurse should encourage the client to ambulate as soon as prescribed and implement range-of-motion exercises while on bedrest to prevent DVT.

A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to an assistive personnel (AP)? A. Verify the client's list of allergies in the medical record B. Assist with placing the client onto the stretcher for transport to the surgical suite C. Complete the preoperative checklist for the client D. Call to inform the provider about the client's preoperative elevated blood glucose leve

Correct Answer: B. Assist with placing the client onto the stretcher for transport to the surgical suite Helping the client onto the stretcher for transport to the surgical suite is a skill that is within the scope of practice for the AP.

A nurse is caring for a client who is undergoing a repair of an abdominal aortic aneurysm. After the surgery and immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the client's ongoing and specific needs for care? A. Charge nurse B. Case manager C. Vascular surgeon D. Home health care nurse

Correct Answer: B. Case manager The case manager's role is to plan and coordinate resources and services to help meet the client's needs over the continuum of care.

A nurse manager establishes staff nurse committees to address unit issues, institutes an open-door policy for speaking about concerns, and supports professional staff development. Which of the following leadership styles is this nurse manager displaying? A. Laissez-faire B. Democratic C. Autocratic D. Transactional

Correct Answer: B. Democratic The democratic manager encourages the staff to participate in decision-making, communicates effectively, offers constructive criticism, and believes the best of people.

A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies to help reduce costs. Which of the following types of leadership is the nurse manager using? A. Autocratic B. Democratic C. Laissez-faire D. Moral

Correct Answer: B. Democratic This is an example of democratic leadership. A democratic leader guides staff toward an objective and shares responsibility with the staff. This is the ideal type of leadership in this situation because a great amount of creativity can occur, and many strategies can be developed.

A nurse in the emergency department is preparing to obtain informed consent for surgery from a client who received a meperidine hydrochloride IV during transport from a rural hospital. Which of the following actions should the nurse take to obtain consent for surgery? A. Obtain consent from the client. B. Obtain consent from a relative of the client. C. Consent is implied because the client agreed to be transported to the emergency department. D. Delay the surgery until the medication has been metabolized.

Correct Answer: B. Obtain consent from a relative of the client. A client who has received meperidine cannot give consent because the medication can alter the ability to understand the consent process. The nurse should obtain consent from a relative of the client. If a relative is unavailable and the surgery is determined to be critical, the surgery can proceed without client consent.

A nurse is caring for a client who had a stroke and requires assistance performing ADLs. The nurse should collaborate with which of the following members of the interprofessional care team? A. Speech-language pathologist B. Occupational therapist C. Social worker D. Dietitian

Correct Answer: B. Occupational therapist An occupational therapist can help clients who have physical limitations or disabilities gain an optimal level of independence in performing ADLs, such as bathing, dressing, grooming, and eating

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? A. Showing the client how to use the patient-controlled analgesia pump. B. Recording urinary output after emptying the indwelling urinary catheter. C. Assisting the client out of bed and into a chair for the first time after surgery. D. Checking the client's abdominal wound dressing.

Correct Answer: B. Recording urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording intake and output are within the scope of practice for an AP. These tasks are routine and have predictable outcomes; therefore, the nurse may delegate this task to an AP.

A nurse working in a mental health facility is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider? A. Occupational therapist B. Social worker C. Physical therapist D. Spiritual support

Correct Answer: B. Social worker The nurse should identify that a social worker assists clients with issues such as finances, day-to-day concerns, and suitable housing options.

nurse in a provider's office observes a newly licensed nurse taking a client's health history while in the waiting area. Which of the following actions should the nurse take? A. Continue to observe the nurse B. Speak to the nurse immediately in private C. Consider using the same practice to make efficient use of time and office space D. Report the nurse's actions to the provider

Correct Answer: B. Speak to the nurse immediately in private The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. Personal health information could be overheard by others in the waiting room. The nurse must immediately stop this behavior and speak to the newly licensed nurse in private to protect the privacy and confidentiality of the client.

A nurse is part of a facility committee charged with developing and implementing new documentation forms. The nurse should recognize which of the following factors as a potential restraining force for implementing this change? A. Approval of the forms by the nursing administration B. Staff members' resistance to learning new forms of documentation C. Recognition of the facility unit that completes the implementation first D. Development of high-quality monitoring tools for compliance with new documentation

Correct Answer: B. Staff members' resistance to learning new forms of documentation Restraining forces impede change. Staff members' resistance to learning a new documentation system can be a restraining force. As a result, the committee must develop a plan for implementation that recognizes this threat.

A charge nurse is providing teaching to a new staff nurse about the management of a team consisting of a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following pieces of information should the charge nurse include in the teaching? A. The LPN can delegate the task of teaching a client about foot care to the AP. B. The LPN should be familiar with the task she plans to delegate. C. The person who accepts the delegated task also assumes accountability for the task. D. The LPN can delegate an initial assessment of a client to the LPN.

Correct Answer: B. The LPN should be familiar with the task she plans to delegate. The nurse should be familiar with the task she plans to delegate so she can define the task as well as the expectation of its completed status, monitor the performance of the task, and provide feedback regarding the performance.

A nurse is caring for an adult client who has pancreatitis. The client tells the nurse, "I've decided that I want to go home. I don't want any more treatment." The nurse should recognize that which of the following legal principles applies to the client? A. The admitting provider needs to approve the client's request to leave. B. The client has the right to make the decision to leave the hospital. C. The client should be detained if leaving presents a risk of loss of life or limb. D. The client must demonstrate self-care abilities prior to leaving the acute-care facility.

Correct Answer: B. The client has the right to make the decision to leave the hospital. Even though the nurse and the provider may think it inadvisable, a client who is not involuntarily admitted has the right to decide to leave at any time. Nurses and providers have a responsibility to ensure that the client is aware of potential risks and injury that can result from leaving and refusing further treatment before discharging the client against medical advice. The nurse should fully document this information and the client's response in the medical record.

A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates an understanding of the teaching? A. The client nods and smiles in response to what is being said. B. The client restates the information in her own words. C. The client does not ask questions when given the opportunity. D. The client's body language shows that she is listening to the nurse. Incorrect, try again

Correct Answer: B. The client restates the information in her own words. When the client restates the information in her own words, the nurse can assess the client's understanding of the teaching. The nurse can observe and listen for gaps in understanding and proceed to correct items as necessary.

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include? A. "A critical pathway is a plan of care specific to the nursing interventions necessary for client care." B. "A critical pathway is a tool that legally binds the health care facility to provide services as outlined. " C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." D. "A critical pathway is a plan that may be the same for several similar diagnoses."

Correct Answer: C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired client outcomes and an appropriate length of stay for the particular diagnosis.

A nurse is teaching a newly licensed nurse about advanced directives. Which of the following statements by the newly licensed nurse indicates an understanding of this teaching? A. "Clients are required to complete an advance directive prior to discharge." B. "If the client has a health care proxy, he/she is no longer consulted for health care decisions." C. "I will assess the client's understanding of life-sustaining measures." D. "I will ask the next of kin if I should honor the client's advance directive." .

Correct Answer: C. "I will assess the client's understanding of life-sustaining measures." The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures in order to make informed decisions in advance directives

A nurse is caring for a client who has cancer. The client tells the nurse he does not want any more chemotherapy treatments. Which of the following responses should the nurse provide? A. "I think you should finish this round of treatments and then see how you feel." B. "I will discuss this decision with the designee in your health care proxy." C. "I will inform your provider of your decision to discontinue the treatments." D. "I am so sorry to hear you are tired of fighting and have made this decision."

Correct Answer: C. "I will inform your provider of your decision to discontinue the treatments." The nurse has a duty to respect the client's right to refuse medical treatment. If a client under the nurse's care refuses treatment, the nurse also has a duty to notify the provider, who should give the client information about the consequences, risks, and benefits of refusing therapy.

A charge nurse on a medical-surgical unit is making client assignments for the oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who requires an updated plan of care following a diagnosis of cancer B. A client who is postoperative following a total hip replacement and requires discharge teaching C. A client who has a prescription for irrigation of an indwelling urinary catheter D. A client who has just arrived from PACU and requires a head-to-toe assessment

Correct Answer: C. A client who has a prescription for irrigation of an indwelling urinary catheter It is within the scope of practice of an LPN to irrigate an indwelling urinary catheter when prescribed by a provider.

A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict? A. Understanding that the unit nurse is misinformed and taking no action B. Assigning the unit nurse to work the night shift to facilitate direct experience with the night shift C. Meeting one-on-one with the unit nurse to discuss these concerns D. Confronting the unit nurse during the next unit meeting regarding this statement

Correct Answer: C. Meeting one-on-one with the unit nurse to discuss these concerns The charge nurse should schedule a time to speak privately with the unit nurse about the situation. Assertive behavior involves discussing a situation directly with the person involved.

A nurse is preparing to care for a group of clients after receiving change-of-shift reports. Which of the following clients should the nurse assess first? A. A client who has benign prostatic hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

Correct Answer: C. A client who has emphysema and reports dyspnea The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the client who has emphysema and reports dyspnea is the first client the nurse should assess.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse attend to first? A. A client who is receiving metoclopramide and reports diarrhea B. A client who is receiving tamsulosin and reports feeling dizzy C. A client who is receiving cephalexin and reports dyspnea D. A client who is receiving erythromycin and reports epigastric pain

Correct Answer: C. A client who is receiving cephalexin and reports dyspnea The greatest risk to this client is an injury from dyspnea due to an allergic reaction from the antibiotic. The client is at risk of anaphylactic shock with a compromised airway; therefore, the nurse should first discontinue cephalexin and notify the provider immediately. Emergency equipment should be placed in the client's room in case the client goes into anaphylactic shock

A school bus crash in the community creates an urgent need for pediatric hospital beds. Which of the following clients should the nurse manager recommend for discharge? A. A school-age child who was admitted the day before with status asthmaticus B. A toddler admitted the day before who has dehydration and is receiving IV fluids C. A preschooler admitted with tonsillitis who has been receiving oral antibiotics for 24 hr D. An adolescent with acute glomerulonephritis whose urine output is 20 mL/hr

Correct Answer: C. A preschooler admitted with tonsillitis who has been receiving oral antibiotics for 24 hr This preschooler admitted with tonsillitis is stable and is receiving oral antibiotics; therefore, the preschooler can be discharged with antibiotics to be continued at home.

A nurse manager is participating in a root cause analysis following a sentinel event on the unit. Which of the following statements defines the purpose of a root cause analysis? A. A root cause analysis assists in preparing a legal defense for the event. B. A root cause analysis estimates the costs involved in the event. C. A root cause analysis investigates deviations from standards of care surrounding the event. D. A root cause analysis determines if employees involved in the event should be terminated.

Correct Answer: C. A root cause analysis investigates deviations from standards of care surrounding the event. A root cause analysis is a function of quality improvement seeking to determine what factors led to a deviation from established standards of care that resulted in errors in client care.

A group of providers is participating in a cardiopulmonary resuscitation effort for a client who is in cardiac arrest. Which of the following types of leadership is required for this group to function efficiently? A. Transformational B. Participative C. Autocratic D. Laissez-faire

Correct Answer: C. Autocratic Autocratic leadership is most effective in an emergency situation. An autocratic leader will direct and issues commands that are necessary for successful cardiopulmonary resuscitation.

A nurse is reviewing the medication administration record for a client and notes that the nurse from the previous shift gave double the dose of antihypertensive medication prescribed to the client. Which of the following actions should the nurse take first? A. File an incident report with factual information about the error B. Report the incident to the nursing supervisor C. Check the client's condition D. Notify the client's provider about the incident

Correct Answer: C. Check the client's condition The greatest risk to this client is an injury from low blood pressure due to a double dose of antihypertensive medication. Therefore, the first action the nurse should take is to check the client's condition and obtain the client's vital signs, including blood pressure.

A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the client on the floor. What is the priority nursing action? A. Notify the provider of the fall. B. Call for help. C. Determine the client's level of consciousness. D. Complete an incident report.

Correct Answer: C. Determine the client's level of consciousness. Checking the client's level of consciousness is the first action the nurse should take after a fall. This client might have had a vasovagal response while defecating, resulting in a temporary loss of consciousness that does not require CPR.

Using high-quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay of 5 days instead of the established standard of 3 days. Which step should the nurse implement next in the quality-improvement process? A. Educate staff members on shortening the length of stay for these clients B. Collect data regarding the length of stay for these clients C. Determine which actions can be instituted to address this problem D. Research the accuracy of the standard of care that has been accepted

Correct Answer: C. Determine which actions can be instituted to address this problem Further analysis of data will identify factors that contribute to longer lengths of stay. Identifying actions to shorten the clients' lengths of stay is the next step in the process.

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? process A. Call the clients' family members to provide additional help with moving the clients. B. Ask clients who are able to ambulate to assist in moving the unstable clients. C. Instruct clients who are able to ambulate to leave. D. Direct staff members to close the doors and windows as each room is evacuated.

Correct Answer: C. Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should leave first in an evacuation process, as this quickly reduces the number of clients who require evacuation assistance.

A nurse is assisting with the informed consent process for a client who is scheduled for a below-the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why they are doing this." Which of the following actions should the nurse take? A. Complete an incident report. B. Administer an antianxiety medication. C. Notify the provider of the client's comments. D. Answer the client's questions and verify understanding.

Correct Answer: C. Notify the provider of the client's comments. It is the nurse's responsibility to notify the provider if the client has questions or appears not to understand the procedure. The provider is responsible for providing clarification. Informed consent is a legal process by which a client gives written permission for a procedure or treatment.

A nurse suspects that a coworker may be in an impaired state when providing care to clients. Which of the following actions should the nurse take? A. Ask other coworkers if they feel the same way. B. Speak directly with the impaired coworker. C. Report these observations to the nurse manager. D. Refuse to work with the impaired coworker.

Correct Answer: C. Report these observations to the nurse manager. The nurse who observes an impaired coworker's performance should report this behavior to the nurse manager. If the coworker is found to be impaired, this action will initiate an appropriate intervention and support, and clients will be protected from the actions of an impaired coworker.

A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts? A. Have the charge nurses for each shift get together and discuss the issues between shifts. B. Direct the nurses from each shift to discuss their issues and present solutions to the nurse manager. C. Set up a series of meetings for all staff members to attend to discuss issues. D. Remain uninvolved and allow the nurses from each shift to resolve the issues among themselves.

Correct Answer: C. Set up a series of meetings for all staff members to attend to discuss issues. Through this approach, the nurse manager is using the conflict-resolution strategy of collaboration by encouraging all staff members associated with the conflict to communicate and work together to devise and implement win-win solutions.

A nurse is admitting a client who has active gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)? A. Obtain the initial set of vital signs B. Listen for bowel sounds C. Show the client how to use the nurse call light D. Ask the client if he has any allergies

Correct Answer: C. Show the client how to use the nurse call light The AP can show the client

A home health care nurse is conducting a home hazard assessment. For which of the following findings should the nurse intervene? A. The client's hot water heater temperature is set to 46.1°C (115°F). B. There are 8 steps to enter the client's home. C. The client's household lamps have 40-watt light bulbs installed. D. The bathroom has a handheld shower attachment for bathing.

Correct Answer: C. The client's household lamps have 40-watt light bulbs installed. The nurse needs to intervene for low-wattage light bulbs. Inadequate lighting increases the risk of falls and presents a safety hazard for the client.

A nurse overhears two other nurses discussing a conflict they are having about who should complete certain client-care tasks. The nurses agree that they are tired of the conflict and will let the nurse manager decide who should complete the tasks. The nurse should identify this outcome as which of the following approaches to conflict management? A. Win-win B. Win-lose C. Win-yield D. Lose-lose

Correct Answer: C. Win-yield A win-yield approach involves both parties no longer trying to resolve the conflict. Instead of taking the initiative to end the conflict, they agree to honor whatever the nurse manager decides. Incorrect Answers: A. A win-win strategy is a collaborative approach. There is no power struggle, and both parties work together for a positive outcome that meets a common goal. B. A win-lose strategy involves one party emerging victoriously and the other losing the struggle. If the losing party continues to pursue the situation, it becomes a competing strategy. D. A lose-lose strategy is also an avoidance approach. The two parties abandon the struggle and take no further action, but the conflict remains. In this outcome, no one wins.

A charge nurse on a pediatric unit is delegating tasks to an assistive personnel (AP) who is pregnant and reports that she is unsure of her immune status. Which of the following clients should the charge nurse assign to the AP? A. A 9-year-old child who has fifth disease B. A 4-year-old child who has varicella (chicken pox) C. A 6-year-old child who has rubella D. A 2-year-old child who has impetigo contagiosa (impetigo)

Correct Answer: D. A 2-year-old child who has impetigo contagiosa (impetigo) This is a safe assignment. If the AP practices universal precautions, there is no risk of contracting impetigo. Impetigo is a superficial skin infection caused by either Staphylococcus or Streptococcus.

A charge nurse receives a call from the nursing supervisor about an explosion at a local factory and an urgent need for facility beds for newly admitted clients. Which of the following clients should the nurse recommend for discharge? A. A 60-year-old client with type 2 diabetes mellitus who was admitted 48 hr ago with uncontrolled glucose levels B. A 58-year-old client who is 12 hr postoperative following a total knee arthroplasty C. An 80-year-old client admitted 24 hr ago for vomiting and dehydration D. A 44-year-old client with asthma who was admitted for carpal tunnel surgery

Correct Answer: D. A 44-year-old client with asthma who was admitted for carpal tunnel surgery A client who is admitted for carpal tunnel surgery is stable and having an elective procedure. Therefore, the nurse should recommend this client for discharge.

A nurse is selecting clients for discharge following an environmental disaster. Which of the following clients should the nurse select? A. A client who had a cast removal due to compartment syndrome B. A client who is scheduled for dialysis and has a potassium level of 6.2 mEq/L C. A client who has type 1 diabetes mellitus and a blood glucose of 320 mg/dL D. A client who is 1 day postoperative following an inguinal hernia repair

Correct Answer: D. A client who is 1 day postoperative following an inguinal hernia repair The nurse should select the client who had an inguinal hernia repair for discharge because this client is stable

A nurse manager is observing the staff members working on her unit. Which of the following actions should the nurse manager recognize as an example of paternalism? A. A nurse asking to care for an older adult client every day who reminds the nurse of a favorite grandparent B. A male nurse caring for an adolescent male client because the client is uncomfortable around female nurses C. A middle-aged adult assistive personnel (AP) mentoring a younger less-experienced AP on the unit D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress

Correct Answer: D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress Paternalism is a type of relationship between clients and health care providers in which the health care providers believe they know what is best for the clients. In this example, the nurse practitioner withholds information so as not to cause the client distress. This practitioner is making the decision for the client and denying the client the right to be informed.

An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel obstruction and is NPO with a nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform? A. Obtain daily weight B. Inspect the client's oral cavity for dryness hourly C. Measure and record the NG tube output every 4 hours D. Assess for bowel sounds every 2 hours

Correct Answer: D. Assess for bowel sounds every 2 hours Assessments are within the scope of practice for the RN only. While the LPN can also auscultate the client's abdomen for the presence of sounds, only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive.

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first? A. Discuss with the charge nurses their responsibility in implementing the change. B. Post a sign-up sheet for in-service training sessions about the new system. C. Ask informal leaders to participate in the early implementation process. D. Collect the staff members' input about planning and implementing the change.

Correct Answer: D. Collect the staff members' input about planning and implementing the change. The nurse manager should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he/she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse manager should first assess the situation by collecting the staff members' input and collaborating about implementing the change smoothly and efficient

A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which priority action should the charge nurse take to address the problem? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service training session about hand hygiene and infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who developed HAIs

Correct Answer: D. Conduct a chart review to gather data about clients who developed HAIs The charge nurse should first conduct a chart review or audit in order to gather data about the clients who developed infections. This information will provide the charge nurse with potential indicators or factors that resulted in the increased incidence of HAIs.

A nurse is planning to perform a negotiation to manage a conflict between himself and another staff member. Which of the following actions should the nurse plan to take? A. Continue the negotiation process until all parties agree on a settlement. B. Establish equality in the concessions that each party makes. C. Make as many concessions as needed to make everyone happy. D. Create a solution in which all parties are satisfied.

Correct Answer: D. Create a solution in which all parties are satisfied. The goal of negotiation is to create a win-win situation in which all parties are satisfied with the results. Both parties involved in the conflict should be willing to make concessions.

nurse is caring for a postoperative client who has an Hgb of 8.0 g/dL. The nurse delegates the administration of a unit of packed RBCs to a nurse floating from a psychiatric unit who is unfamiliar with blood administration. Which of the following actions should the float nurse take? A. Call the provider to clarify the prescription for administering the unit of packed RBCs. B. Hang the unit of blood if the charge nurse agrees to be a resource. C. Question the nurse regarding this prescription due to the client's reported Hgb level. D. Decline to hang the blood.

Correct Answer: D. Decline to hang the blood. The nurse has a legal duty to decline tasks that cannot be performed safely and competently. A float nurse from a psychiatric unit would not be familiar with the current policy regarding blood administration, and this nurse has limited experience with this procedure.

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the change, and the nurse manager notes that this nurse does not deliver care according to the new policy. Which of the following actions should the nurse manager take? A. Explain the disciplinary consequences of refusing to implement the new policy. B. Reinforce with the staff nurse the importance of implementing the policy change. C. Ignore the staff nurse's resistance and allow peer pressure to facilitate the change. D. Encourage the staff nurse to verbalize reasons for resisting the change.

Correct Answer: D. Encourage the staff nurse to verbalize reasons for resisting the change. The nurse manager should realize that if the nurses who must implement the change are not invested in the change process, resistance is likely. This is especially problematic when the change is unplanned or imposed by outside forces. The resistant staff nurse has likely rejected the change due to prior habits, fear of the unknown, and lack of time to learn something new. A meeting between the nurse manager and the staff nurse will provide an open forum for the staff nurse to verbalize the reasons for reluctance in adopting the new policy.

A nurse is having difficulty completing care and documentation without staying past the end of the shift. The nurse manager suggests focusing on time-management skills. Which of the following strategies should the nurse plan to use? A. Practice multitasking throughout the shift B. Postpone completing documentation until the end of the shift C. Occasionally skip a break time D. Identify tasks in order of their priority

Correct Answer: D. Identify tasks in order of their priority Prioritizing is an important time-management strategy. The nurse should prioritize each client's needs and tasks and attend to the highest priority client first

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effects from the error. What is the purpose of completing the incident report? A. Alerting the facility administration of a possible litigation situation B. Tracking employee performance for possible disciplinary action C. Providing a detailed report of the occurrence for the client's family D. Identifying situations that contribute to the occurrence of medication errors

Correct Answer: D. Identifying situations that contribute to the occurrence of medication errors The purpose of completing incident reports is to identify factors that contribute to the occurrence of the problem. This is one aspect of quality-improvement efforts in health care facilities.

A nurse manager is implementing a team nursing approach on his unit, hiring licensed practical nurses (LPNs) and assistive personnel (AP) as additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change? A. Develop a plan for the change and present it during a staff meeting. B. Explain that this change is a request from the administration and will be carried out. C. Hire new LPNs and APs and gradually integrate them into the staff. D. Introduce the new approach and facilitate the development of a task force to plan implementation.

Correct Answer: D. Introduce the new approach and facilitate the development of a task force to plan implementation. This appropriate approach involves the staff in the planning and will give them a feeling of control over their practice and enhance acceptance of the change.

A new nurse manager on a busy oncology unit keeps her door closed when she is in the office and does not offer to help resolve daily staffing issues. Which of the following types of leadership behavior is this nurse manager displaying? A. Transformational B. Democratic C. Autocratic D. Laissez-faire

Correct Answer: D. Laissez-faire This nurse manager is a laissez-faire leader, providing little support or guidance. The leader's activity is minimal and contributes to reduced staff efficiency.

A nurse enters a client's room and discovers a small fire in a trash can. Which of the following actions should the nurse take first? A. Place moist towels or blankets at the threshold of the door of the room with the fire. B. Close fire doors and doors to client rooms C. Pull the fire alarm and notify the hospital operator. D. Move the client out of the room.

Correct Answer: D. Move the client out of the room. The nurse should apply the safety and risk-reduction priority-setting framework when responding to a fire. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, to ensure the safety of the client, the nurse should move the client out of the room

A nurse is caring for a client who has recently been prescribed lithium carbonate. Which of the following assessment findings is the priority for this client? A. Fine hand tremors B. Weight gain of 2.7 kg (6 lb) C. Report of nausea D. Poor motor coordination

Correct Answer: D. Poor motor coordination When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is poor motor coordination, which is an advanced manifestation of lithium carbonate toxicity. The nurse should hold the client's medication and notify the provider.

While participating in a continuous quality-improvement program, a nurse is reviewing medical records to determine the time of first postoperative ambulation of clients who had abdominal surgery. In which type of quality audit is the nurse participating? A. Outcome B. Structure C. Strategic planning D. Process

Correct Answer: D. Process A process audit measures the interventions used to facilitate expected and desired outcomes for clients. Early ambulation is essential for the prevention of postoperative complications.

While participating in a continuous quality-improvement program, a nurse is reviewing medical records to determine the time of first postoperative ambulation of clients who had abdominal surgery. In which type of quality audit is the nurse participating? A. Outcome B. Structure C. Strategic planning D. Process

Correct Answer: D. Process A process audit measures the interventions used to facilitate expected and desired outcomes for clients. Early ambulation is essential for the prevention of postoperative complications.

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of the Quality and Safety Education for Nurses (QSEN) initiative? A. Safety B. Informatics C. Patient-centered care D. Quality improvement .

Correct Answer: D. Quality improvement This QSEN competency involves using data to track outcomes with the goal of devising processes to improve clients' outcomes. Incorrect Answers: A. This QSEN competency involves using national safety guidelines and goals to provide safe client care. B. This QSEN competency involves navigating clients' electronic health records and using technology effectively to manage client care. C. This QSEN competency involves determining clients' needs, preferences, and values and providing care that addresses these parameters.

A nurse manager notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the nurse manager plan to take? A. Make a general announcement at the next staff meeting asking all employees to check their adherence to the requirement. B. Post a list in the employees' break room naming those who are non-adherent and the date by which they must complete the requirement. C. Schedule a disciplinary conference with each of the non-adherent employees. D. Send an email to each non-adherent employee that includes a link to upcoming educational sessions.

Correct Answer: D. Send an email to each non-adherent employee that includes a link to upcoming educational sessions. Email provides a simple yet efficient way for the nurse manager to inform non-adherent employees about options for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the email facilitates adherence by helping each employee identify an upcoming session that coordinates with his/her work schedule.n

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? A. Hgb 12 g/dL B. WBC 15,000/mm^3 C. Fasting blood glucose 80 mg/dL D. Serum creatinine 0.4 mg/dL

Correct Answer: D. Serum creatinine 0.4 mg/dL This value is below the expected reference range for a client who is pregnant. The nurse should report this value to the provider. The other values are within the expected reference range for a client who is pregnant.

A charge nurse is planning a performance appraisal for a newly hired assistive personnel (AP). Which of the following factors should the charge nurse take into consideration when planning a performance appraisal interview for the AP? A. The performance appraisal interview should be friendly and informal. B. Aside from the charge nurse, no one should have input regarding the AP's appraisal. C. A nursing administrator who does not know the AP should conduct the interview to promote fairness. D. The AP should have a copy of the performance standards before the appraisal interview.

Correct Answer: D. The AP should have a copy of the performance standards before the appraisal interview. The AP should have a copy of the performance standards prior to the interview in order to indicate what his/her performance is being measured against

A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? A. Whether the AP has consented to the performance of delegated tasks B. The client's willingness to consent to care from the AP C. Whether the task can be more efficiently completed by the nurse D. The degree of supervision that the AP will require to complete the task

Correct Answer: D. The degree of supervision that the AP will require to complete the task Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided. The right communication of expectations and the right feedback about performance must also be supplied.

A nurse is teaching a newly licensed nurse about the informed consent process for a client who is scheduled for a surgical procedure. Which of the following pieces of information should the nurse include in the teaching? A. Clerical staff in the facility can witness the signature of a client on a consent form. B. The nurse caring for a client is responsible for explaining the procedure. C. A family member should be present when a client signs a consent form. D. The person who will perform the procedure is responsible for obtaining informed consent.

Correct Answer: D. The person who will perform the procedure is responsible for obtaining informed consent. The person performing the procedure is legally responsible for obtaining informed consent. Informed consent includes telling the client about the risks and benefits of the procedure, alternative treatments available, and possible outcomes if the procedure is not performed.

A nurse on a medical-surgical unit is delegating tasks to nursing team members. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Instructing a client how to use a glucometer B. Instilling lubricating eye drops for a client C. Evaluating the effectiveness of a client's pain medication D. Transferring a client who is postoperative from a bed to a chair

Correct Answer: D. Transferring a client who is postoperative from a bed to a chair Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, and other simple procedures that do not involve assessment or teaching.

A nurse is ambulating a client who has an IV with an infusion pump. After the nurse returns the client to his room and plugs in the infusion pump, the client reports a slight tingling in his hand. Which of the following actions should the nurse take? A. Plug the pump into a different outlet. B. Place a service tag on the pump for a routine inspection. C. Unplug the pump and plug it back into the same outlet to see if the sensation of tingling is repeated. D. Turn off the pump.

Correct Answer: D. Turn off the pump. The pump must be turned off immediately to protect the client and the nurse from the risk of electrical injury and fire. The nurse should consider any electrical equipment that shows a sign of malfunction to be unsafe and place it out of service until it can be checked by the facility's maintenance department.

A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse? A. Explaining the procedure to the client B. Offering alternative treatments C. Informing the client of the consequences of refusing the procedure D. Verifying the client's understanding of the procedure being performed

Correct Answer: D. Verifying the client's understanding of the procedure being performed The nurse must verify that the client understands and can describe the procedure being performed.

after a disaster plan is enacted, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged home due to a local incident involving many children. Which of the following clients should the nurse place on the potential discharge list? (Select all that apply.) A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics D. A toddler with a ventricular septal defect and bronchiolitis who is on 28% oxygen by oxyhood E. An adolescent client who is 1 day postoperative following scoliosis repair and is on a PCA pump

Correct Answers: A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics The nurse should place clients who can be quickly and safely discharged on the potential discharge list. Children who have asthma can be managed at home once the acute phase of illness has resolved. Because the preschool client's manifestations are responsive to the prescribed medication, this child can be safely discharged home with appropriate discharge teaching and follow-up care planning. External fixation devices are worn for weeks to months; they are often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This school-age client's pain is responsive to oral codeine. Prior to discharge, the client might need instructions on ambulation and weight-bearing, as prescribed. Long-term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse can assist this adolescent client with home care management. The client's developmental delay has no bearing on whether the client is safe to discharge.

A nurse manager is evaluating the time-management strategies of a newly licensed nurse on the pediatric unit. Which of the following actions taken by the nurse are effective time-management strategies? (Select all that apply.) A. Completing one task before beginning another task B. Documenting client care at the end of the shift C. Taking time to plan care at the beginning of the shift D. Completing more time-consuming tasks at the end of the shift E. Mentally visualizing a procedure prior to gathering equipment

Correct Answers: A. Completing one task before beginning another task C. Taking time to plan care at the beginning of the shift E. Mentally visualizing a procedure prior to gathering equipment Completing one task before beginning another task, planning care at the beginning of the shift, and mentally visualizing a procedure prior to gathering equipment are effective time-management strategies for the newly licensed nurse. Daily planning is important for managing and prioritizing tasks.

A nurse suspects that a coworker is under the influence of alcohol. Which of the following behaviors in the workplace are consistent with substance use disorder? (Select all that apply.) A. Taking extended lunch periods and breaks B. Calling in sick frequently on Mondays or Fridays C. Expressing frustration with work assignments D. Demonstrating decreased concern about personal appearance and grooming E. Using excessive amounts of cologne or mouthwash

Correct Answers: A. Taking extended lunch periods and breaks B. Calling in sick frequently on Mondays or Fridays D. Demonstrating decreased concern about personal appearance and grooming E. Using excessive amounts of cologne or mouthwash Extended lunch periods and breaks may indicate that the individual is ingesting alcohol in a remote location. Calling in sick frequently on Mondays or Fridays may imply that the individual is binge drinking on weekends and is too ill to come to work. Decreased concern about personal appearance and grooming and excessive use of cologne or mouthwash are signs of substance use disorder. Incorrect Answer: C. Frustration with assignments is a common workplace behavior but does not necessarily indicate substance use disorder.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.) A. Collecting a stool specimen B. Providing instructions about using a spirometer C. Measuring oral intake D. Providing postmortem care E. Changing a sterile dressing

Correct Answers: A. Collecting a stool specimen