Management of Care Quiz

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish client outcomes.

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 correct entry in the client's medical record?

"The client ambulated for 10 min three times during the shift."

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?

"Transport the client in room 203 to the radiology department at 1000.

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse is caring for a client who has multiple medication allergies. During which of the following steps of the nursing process should the nurse identify the client's allergies?

Assessment

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information

A nurse on a surgical unit is receiving a client who had abdominal surgery from the post anesthesia care unit. Which of the following assessments should the nurse make first?

Airway

A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse perform first?

Ask the client about any over-the-counter medications she is taking

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication.

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who has a stage 111 pressure ulcer on the heel. When preparing to irrigate the wound which of the following actions should the nurse take first?

Check the client's pain level

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum

A nurse is teaching a newly hired assistive personnel about helping older adult clients with activities of daily living (ADLs). Which of the following is the most common factor that affects a client's performance of ADLs?

Chronis physical disability

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)?

Collecting a stool specimen Measuring oral intake Providing postmortem care

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?

Identify tasks in order of their priority

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate

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)?

Measuring vital signs

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

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?

Paralysis of a client's lower extremities occurred following epidural anesthesia.

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

Planning

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24 hr

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication

A nurse is caring for a client and asks, "How are you?" The client responds, "My leg still hurts." Which of the following communication techniques should the nurse use first?

Seek clarification

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?

The degree of supervision that the AP will require to complete the task.

A school nurse is called to the scene of a large fight that just ended. The school security officers have called the police to the scene. Which of the following actions should the nurse take first?

Triage the injured students.