NCLEX ATI PRACTICE: LEADERSHIP ASSESSMENT:

Nurse has assigned client care activities to an AP. Which statement by the AP indicates a need for assistance in establishing priorities? A) "I have my assignment and will start with room 1, then work my way to room 10" B) "I will give this client his meal tray first, as he is going early to physical therapy" C) "After breakfast, I will pack the belongings of clients who will be discharged this morning" D) "I will start by providing partial baths before breakfast"

A) "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.

Nurse is planning to use the SBAR communication tool when calling a provider. Which statement should the nurse include in the B step? A) "The client should be seen by a neurologist" B) "The client was found unconscious on the floor in her home" C) "There are no provider's prescriptions available" D) "The client is disoriented. Pupils are slow to respond to light"

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

Nurse on a surgical unit is caring for a group of clients. Which is the priority action of the nurse? A) Taking a telephone prescription about a client who is to be transferred from the PACU B) Assessing a client who experiences unilateral calf pain when ambulating C) Reinforcing a client's dressing for the surgical site of an above-the-knee amputation D) Reassuring the partner of a client who sustained a closed head injury

B) 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.

Charge nurse is discussing disaster response with nursing staff. Which statement indicates an understanding of the Hospital Incident Command System (HICS)? A) "HICS ensures that necessary antibiotics and antidotes are available" B) "HICS is focused on having multidisciplinary responders available" C) "HICS identifies facility responsibilities and channels of reporting" D) "HICS provides additional responders when needs exceed the ability of local or state agencies"

C) "HICS identifies facility responsibilities and channels of reporting"

Client who is terminally ill tells a nurse on the med-surg unit that she feels hopeless. Which statement by the nurse is appropriate? A) "Tell me why you feel hopeless" B) "I am sure these feelings will pass once you go home" C) "If I were you, I would ask for a referral to hospice care" D) "Tell me what you understand about your illness"

D) "Tell me what you understand about your illness" - The nurse should use this statement to encourage the client to express her feelings and concerns.

An RN is delegating care activities to a LPN. Which is the priority criterion the RN should consider when delegating? A) Agency policies for the LPN B) The documented experience level of the LPN C) The documented skill level of the LPN D) State Nurse Practice Act for the LPN

D) State Nurse Practice Act for the LPN

Charge nurse is working with an AP who provides excellent care to clients and is an effective team members. Which action should the nurse take first to recognize the AP's contributions to client care? A) Give positive feedback directly to the AP B) Tell other nurses what an effective team member the AP is C) Nominate the AP for the Employee of the Month award D) Detail the AP's contributions to the nurse manager

A) Give positive feedback directly to the AP - Positive reinforcement is one of the most effective ways to recognize an employee's ability and to motivate the employee.

Nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which responses by the nurse demonstrates assertiveness? A) "I feel as though I met the standard of care. Would you tell me more about your concerns?" B) "You shouldn't make accusations. Your nursing care doesn't always set a good example" C) "I am at a loss for words. I always do my best to give good care to my clients" D) "What do you have against me? It must be something or you wouldn't be criticizing my care"

A) "I feel as though I met the standard of care. Would you tell me more about your concerns?" - Communicating assertively is expressing thoughts in an open, honest, and direct manner that demonstrates respect for self and others. - The use of "I" statements, maintaining eye contact, and congruent verbal and facial expressions are all components of assertiveness skills. - The nurse demonstrates respect for the opinion of the other nurse by asking for feedback and the reason for the concerns.

Nurse manager is reviewing the Good Samaritan laws with a group of new nurses. Which statement by the nurse manager is appropriate? A) "If you render aid in an accident, do not leave the scene until another competent person can take over" B) "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse" C) "Federal laws require a licensed nurse to render aid in an emergency" D) "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws"

A) "If you render aid in an accident, do not leave the scene until another competent person can take over" - Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives.

Nurse has received change-of-shift report and is delegating tasks to the AP. The nurse should tell the AP to complete which tasks first? A) Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast B) Apply a condom catheter to a client who is incontinent C) Feed a client who has bilateral casts due to upper arm fractures D) Deliver a clean voided urine specimen to the lab

A) Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast - When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority task to delegate is the blood glucose monitoring for the client who has an insulin prescription. - This task is time sensitive and should be completed first.

Nurse working in the ER is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which intervention should the nurse plan to take? A) Vigorously rub the skin following a decontamination shower B) Initiate seizure precautions C) Provide respiratory support with a plastic oral airway D) Prepare to administer amyl nitrate

B) Initiate seizure precautions - Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. - The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen.

Nurse and an experienced LPN are caring for a group of clients. Which tasks should the nurse delegate to the LPN? SATA A) Provide discharge instructions to a confused client's spouse B) Obtain vitals from a client who is 6 hr post-op C) Administer a tap-water enema to a client who is post-op D) Initiate a plan of care for a client who is post-op from an appendectomy E) Catheterize a client who has not voided in 8 hr.

B) Obtain vitals from a client who is 6 hr post-op C) Administer a tap-water enema to a client who is post-op E) Catheterize a client who has not voided in 8 hr.

Nurse is assessing a newly licensed nurse with delegating tasks to an AP on the unit. Which statement by the nurse explains the purpose of delegation? A) "Delegation provides appropriate resources for the client" B) "Delegation permits a designated individual to meet a goal on your behalf" C) "Delegation promotes discharge teaching activities for clients" D) "Delegation decreases health care costs"

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

Nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which statement by the client indicates a contraindication for taking this med? A) "I had strep throat about a year ago" B) "I plan to continue nursing my baby until he is at least a year old" C) "I got my flu shot at the pharmacy two weeks ago" D) "I am allergic to shellfish"

B) "I plan to continue nursing my baby until he is at least a year old" - Glyburide is a sulfonylurea that is used to treat type 2 diabetes, but it is contraindicated during pregnancy and breastfeeding.

Nurse in a provider's office is reviewing the lab findings for a client who is scheduled for surgery. Which findings require follow up by the nurse? A) BUN 15 mg/dL B) Platelet count 60,000/mm3 C) WBC 6,000/mm3 D) Hemoglobin 15 g/dL

B) Platelet count 60,000/mm3 - This platelet count is below the expected reference range. - A low platelet count places the client at risk for bleeding; therefore, the nurse should follow up on this finding.

Nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which person should sign the informed consent? A) The client's partner B) The client C) The client's daughter, who is the primary caregiver D) The client's son, who has durable power of attorney

B) The client - If the client appears competent, and understands the procedure, the client can sign for informed consent. - The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. - If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

Nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which statement by the client indicates a need for clarification?A) "I can change who i designate as my health care proxy at any time" B) "If I become incapacitated, end-of-life choices will be made by my proxy" C) "I have to choose a family member as my health care proxy" D) "The health care proxy does not go into effect until I am incapable of making decisions"

C) "I have to choose a family member as my health care proxy"

Charge nurse is reviewing the list of tasks that have been delegated to the AP by the staff nurse. Which tasks should the charge nurse reassign to a licensed nurse? A) Transporting a client who experienced a stroke 72 hr ago to the radiology department B) Providing a back rub to a client who has right-sided paralysis C) Removing and cleaning the cannula of a client who has a new tracheostomy D) Performing oral hygiene for a client who is 1 day post-op following an amputation of the right arm

C) Removing and cleaning the cannula of a client who has a new tracheostomy - Removing and cleaning the cannula of a client who has a new tracheostomy requires use of the nursing process, specialized knowledge, and clinical judgment; therefore, this task should be reassigned to a licensed nurse.

Nurse is serving on a continuous quality improvement committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which strategy should the committee plan to initiate first? A) Provide an in-service on medication administration to all nurses B) Require the staff nurses to demonstrate competency by passing a medication administration exam C) Review the evens leading up to each medication administration error D) Develop a quality improvement program for nurses involved in medication administration errors

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

Charge nurse has assigned a group of clients to a LPN. The charge nurse receives report from her assigned clients about the LPN's lack of care. Which action should the charge nurse take? A) Review the LPN's personnel file B) Discuss the LPN's behavior with other nurses on the unit C) Talk with the clients who have reported the LPN's lack of care D) Reassign some of the LPN's client care to AP

C) Talk with the clients who have reported the LPN's lack of care - The charge nurse should investigate the allegations of misconduct to determine if disciplinary action is warranted.

Nurse is supervising a LPN who is providing care to a client who is post-op. Which statement by the client requires the nurse to follow up with the LPN? A) "I don't know who to make the remote control work" B) "Do you know when I will be going home?" C) "My dressing was changed earlier this morning" D) "I have not received any of my meds. today"

D) "I have not received any of my meds. today" - Failure to receive prescribed medications in a timely manner can have a negative effect on client outcomes. - The nurse should immediately follow up with the PN to determine if medications have been administered and, if not, to learn why. - It is possible that the client does not remember receiving medications or that no medications were been prescribed as of this time. - Effective supervision requires that any issue that can negatively impact client care is followed up on immediately.

Nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic med. to a competent client after the client has refused is an example of which tort? A) Assault B) False imprisonment C) Negligence D) Battery

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

Nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which actions by the nurse indicates the nurse manager should intervene? A) The nurse uses clean gloves when discontinuing a client's intravenous infusion B) The nurse empties a client's drainable colostomy pouch when it is 1/3 full C) The nurse uses the client's phone number as one form of identification when administering meds. to a client D) The nurse opens a top flap of a sterile tray toward the body when assisting the provider with a thoracentesis

D) The nurse opens a 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. - The nurse should use two forms of identification prior to administering medications to a client. Acceptable forms of identification include telephone number, as well as the client's name and birthdate.

Charge nurse is making assignments for nursing personnels who will care for clients during the oncoming shift. Which factor should the nurse consider? A) The most experienced nurse receives the most complex clients B) Personal comfort level in making the assignments C) Social relationships between nurses working the oncoming shift D) The physiologic status of the clients on the unit

D) The physiologic status of the clients on the unit - Making assignments requires knowing the physiologic status of the clients on the unit, such as the stability of the clients' vital signs, the amount of health education they need, and the complexity of care involved. - Clients who have an unstable physiologic status may require a higher level of skilled care.

Charge nurse notes that a staff nurse delegates an unfair share of tasks to the AP and the nurses on the next shift report the staff nurse frequently leaves tasks uncompleted. Which statements should the charge nurse make to resolve this conflict? A) "I need to talk to you about unit expectations regarding delegating and completing tasks" B) "Several staff members have commented that you don't do your fair share of the work" C) "If you don't do your share of the work, I will have to inform the nurse manager" D) "You have been very inconsiderate of others by not completing your share of work"

A) "I need to talk to you about unit expectations regarding delegating and completing tasks" - This statement opens the conversation in a non-threatening way. - The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.

Nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which statement by the nurse manager is appropriate? A) "Let's talk about your concerns about the new policy" B) "Why didn't you voice your concerns before the new policy was implemented?" C) "Being open to change is an expectation of the nurses who work on this unit" D) "You should support this policy change bc it was based on evidence-based practice"

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

An AP comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which statement by the nurse is appropriate? A) "There is a higher risk of infection of our clients associated w/ artificial nails" B) "You should know that artificial nails have a very unprofessional appearance" C) "I want you to review the facility's policy on personal attire before you begin the shift" D) "Why would you wear artificial nails to work when you know it's against the rules?"

A) "There is a higher risk of infection of our clients associated w/ artificial nails" - Short, natural nails are less likely to harbor pathogens that can be harmful to clients. - The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. - Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.

Nurse and AP are providing care for 4 clients who were admitted to the med-surg unit on the previous shift. The nurse should delegate meal assistance for which clients to the AP? A) A client who has a lumbosacral spinal tumor B) A client who has Guillain-Barre syndrome C) A client who has amyotrophic lateral sclerosis (ALS) D) A client who has systemic sclerosis

A) A client who has a lumbosacral spinal tumor - The nurse should delegate a task to the AP that is safe for a specific client. - The client who has a lumbosacral spinal tumor is not at risk for dysphagia; therefore, the nurse should delegate meal assistance to the AP for this client.

Nurse in the ER is triaging clients following a mass casualty event. Nurse should identify which of the following clients as emergent? A) A client who has a punctured femoral artery B) A client who has multiple fractures C) A client who has a red rash over his abdomen D) A client who reports severe flank pain radiating to the groin

A) 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.

Nurse manager is reviewing the admission history of 4 adults who were admitted to the med-surg unit during the shift. Which situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances? A) A dependent adult admitted for the treatment of a spiral fracture B) A young adult client admitted for asthma and has track marks that may indicate IV drug abuse C) A young adult client admitted for acute glomeruloneprhitis following a viral infection D) An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

A) A dependent adult admitted for the treatment of a spiral fracture - Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. - Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. - It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. - Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult.

Nurse is teaching a class on torts. The nurse should include which situation as an example of negligence? A) A nurse identifies the absence of peripheral in a casted extremity in the early morning and reports it to the provider in the early afternoon B) A client who's competent refuses an antidepressant med. The nurse dissolves the med. in food and administers it to her without her knowledge C) A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving D) A nurse finds a client who is on low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips

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

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 clients should the nurse recommend for discharge? A) A young adult client who has Crohn's disease and is 1 day pre-op for an ileostomy B) An adolescent who was admitted 24 hr ago due to a spontaneous pneumothorax C) A middle adult who is 36 hr post-op from an open laminectomy D) An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32

A) A young adult client who has Crohn's disease and is 1 day pre-op 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.

Nurse is planning to assign care activities to the AP on her team. Which activities can the nurse assign to the AP? SATA A) Accompany a client who has depression to occupational therapy B) Assess a client who has hypomania for exhaustion C) Check the position of a client in soft wrist restraints D) Set limits with a client who has mania E) Sit with a client who has alcohol use disorder and whose last drink was 5 days ago

A) Accompany a client who has depression to occupational therapy C) Check the position of a client in soft wrist restraints E) Sit with a client who has alcohol use disorder and whose last drink was 5 days ago

Nurse is planning to assign tasks for a group of clients. Which tasks should the nurse assign to an AP? SATA A) Ambulate an older adult client who has hypertension B) Provide discharge instructions for a client who has a new skin graft C) Perform an admission assessment on a client D) Check a blood product with another nurse prior to administration E) Weigh a client who has heart failure

A) Ambulate an older adult client who has hypertension E) Weigh a client who has heart failure

Nurse has been reassigned from her regular area of work to a unit that is short staffed. Which action should the nurse take first? A) Ask what she will be assigned to do B) Determine if she has the skills to complete the assignment C) Identify her options D) Notify the nurse manager about her concerns for client safety

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

Nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from a provider, but he has not written the order yet. Which action should the nurse take? A) Call the emergency response team B) Seek immediate help from the risk manager C) Call the provider for a stat DNR order D) Respect the family's wishes and do nothing

A) 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.

Nurse is preparing to administer a prescribed med. to a client. Which action should the nurse plan to demonstrate client advocacy? A) Encourage the client to verbalize questions B) Insist the client take prescribed meds. C) Inform the client that the medication is the same as taken at home D) Tell the client that refusal of the med. is considered non-compliance

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

Nurse suspects that a coworker is diverting opioid analgesics. Which is an adverse effect of opioid medication? A) Euphoria B) Rhinorrhea C) Hallucinations D) Dilated pupils

A) Euphoria - Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors.q

An AP tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the med. to clients. Which action should the nurse manager take first? A) Gather data about the nurse's work performance and attendance history B) Approach the involved nurse to discuss the behavior C) Notify the risk manager D) Refer the nurse to the board of nursing division program

A) Gather data about the nurse's work performance and attendance history - The first action the nurse should take is to conduct an investigation and determine if the allegations are true.

Nurse overhears 2 AP's from the med-surg unit discussing a hospitalized client while in the cafeteria. Which is the priority nursing action? A) Quietly tell the AP that this is not appropriate B) Ask the nurse manager to provide an in-service program about confidentiality to the staff on the unit C) Complete an incident report D) Document the occurrence in a personal log

A) Quietly tell the AP that this is not appropriate - The nurse has a professional duty to protect the client's confidential information. - When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.

Nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which non-verbal communication techniques to enhance the importance of the announcement? A) Sit in front of the group for the meeting then stand for the announcement B) Cross her arms over her chest when beginning the announcement C) Stare at the people the announcement will affect the most D) Lean gently over the back of a chair sitting to one onside of the room when making the announcement

A) Sit in front of the group for the meeting then stand for the announcement - The weight of a message increases when the sender stands.

Nurse has several tasks to delegate to an AP. Which tasks should the AP perform first? A) Take ABG specimen to lab B) Transport a client to the radiology department for an x-ray C) Pass fresh water to clients on the unit D) Obtain a routine urine sample from a newly-admitted client

A) Take ABG specimen to lab - When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. - ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.

Staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion would get increased consideration. Which action should the staff nurse take first? A) Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately B) Report the behavior to the nurse manager C) Create a written document of the incident and store the document in a safe place D) Seek help from a trustworthy friend

A) Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately - Sexual harassment is unwanted sexual advances made in the context of a relationship of unequal power or authority. - It is experienced as offensive in nature. - The nurse should first start by taking the most direct measure: confronting the hiring manager and insisting the harassment stop.

Nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which should the nurse include in the incident/variance report? (SATA) A) The date of the incident B) The name of the provider who prescribed the med. C) The potential adverse effects of the med. D) The time the client was to receive the med. E) The client's vital signs

A) The date of the incident D) The time the client was to receive the med. E) The client's vital signs - When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date. - The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication. - The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report.

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions should the charge nurse intervene? A) The nurse separates the client's labia with her dominant hand B) The nurse coats the indwelling urinary catheter with lubricant C) The nurse provides perineal care prior to inserting the urinary catheter D) The nurse applies the sterile drape prior to inserting the urinary catheter

A) The nurse separates the client's labia with her dominant hand - The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. - The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. - If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.

Nurse is planning to delegate tasks to a LPN. Which entities is important to the nurse to understand when delegating tasks to the LPN? A) The state Nurse Practice Act B) The National Association for Practical Nurse Education and Services C) The National Council of State Boards of Nursing Decision Tree D) The Omnibus Budget Reconciliation Act of 1987

A) The state Nurse Practice Act

Charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the med-surg unit. Which action should the charge nurse take during the moving stage of change? A) Assess the problem B) Use tactics to alert staff nurses that a change is needed C) Evaluate the effectiveness of the change D) Set a target date

D) Set a target date - During the moving stage, the charge nurse should develop the plan for change and set the target date.

Nurse on a med-surg unit is assigning tasks to an AP. Which tasks should the nurse delegate to the AP? (SATA) A) Demonstrate the technique to instill eye drops B) Ambulate a client who has a cane C) Irrigate a wound D) Transfer a client to a stretcher E) Record urinary output

B) Ambulate a client who has a cane D) Transfer a client to a stretcher E) Record urinary output - It is not within the scope of practice for an AP to demonstrate medication administration. An RN should perform a task that requires client teaching.

Nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which statement by the client indicates an understanding of hospice care? A) "I will have to be admitted to a long-term care facility in order to receive hospice care" B) "I should expect the hospice team to help me manage my dypsnea" C) "Hospice care services are available to patients who are terminally ill regardless of their life expectancy" D) "My oncologist will continue to look for a cure for my cancer while I'm receiving hospice care"

B) "I should expect the hospice team to help me manage my dypsnea" - 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. - Hospice care is available to clients who have a prognosis of 6 months or fewer to live.

Nurse is receiving change-of-shift report at the start of a shift. Which statement by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the AP? A) "The client's family members have been present most of the day" B) "The client's BP and pulse have been fluctuating throughout the day" C) "The client discussed having prior thoughts of suicide" D) "The client works in the hospital radiology department"

B) "The client's BP and pulse have been fluctuating throughout the day" - Knowing the client and the stability of his condition is a criterion to consider when delegating to the AP. - To promote client safety, the more stable clients should be chosen when delegating tasks to APs.

Charge nurse is providing an in-service for staff nurses on the new use of IV pumps. Which actions should the charge nurse take to best evaluate staff competency with the new equipment? A) Ask each nurse to read the procedure and sign a form acknowledging competency B) Allow time during the workday when each nurse can demonstrate proficiency C) Require each nurse to take a written exam about the new equipment D) Verbally question the staff about the new equipment

B) Allow time during the workday when each nurse can demonstrate proficiency - According to evidenced-based practice, the best action to evaluate competency with a psychomotor skill is by return demonstration. - Ensuring that each nurse knows how to use the equipment through return demonstration is the best way to measure correct use of the new equipment. - Prior to full implementation of any new equipment, the supervisory team should allow time for training and proficiency checks to ensure that client care is not compromised.

Nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what to do. Which responses by the nurse is appropriate? A) "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs" B) "What do you think your spouse would have wanted?" C) "Most religions support organ donation, so don't let that stand in the way" D) "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

B) "What do you think your spouse would have wanted?" - Federal law requires facilities to have policies and procedures in place about making a request for organ and tissue donation at the time of death. - The request is made by an employee, often a social worker, who has advanced training and can request the donations in a caring, sensitive manner. - The role of the nurse is to provide emotional support to the family. - Family members should consider the deceased person's wishes when making their decision.

Nurse is caring for 4 clients on a med-surg unit. Which clients should the nurse assess first? A) A client who has NG tube for decompression and the gastric aspirate is green with a pH of 5.3 B) A client who had an indwelling urinary catheter removed 5 hr. ago and has not voided C) A client who has COPD and the capillary refill time on both hands is 4 seconds D) A client who has late-stage cirrhosis and whose breath has a fruity odor

B) A client who had an indwelling urinary catheter removed 5 hr. ago and has not voided - After removal of an indwelling urinary catheter, the client should void within 4 hr. - If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore, when using the priority-setting framework of urgent vs. nonurgent, this client should be assessed first because he has not voided for 5 hr.

Nurse is assessing 4 clients on a med-surg unit. Which should the nurse care for first? A) A client who has diarrhea and requests clear liquids for breakfast B) A client who has a cast on the left leg and reports numbness and paresthesia C) A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D) A client who has pneumonia and has an axillary temperature of 38C (101F)

B) 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 ABC approach to client care, the nurse should care for this client first.

Nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A) A client who has diabetes mellitus and is having difficulty self-administering insulin b/c of poor eye sight B) A client who has terminal cancer and needs assistance with pain management C) A client who is recovering from a stroke and needs someone to provide care while his spouse is at work D) A client who has dementia and needs help with activities of daily living

B) A client who has terminal cancer and needs assistance with pain management

Nurse has received morning report on the following 4 clients. Which should the nurse assess first? A) A client who has administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache B) A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL C) A client who was administered erythromycin for acute glomerulonephritis and reports a reddish-brown urinary output D) A client who was administered acyclovir for cellulitis reports pain in the affected leg

B) A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL - When using the acute vs. chronic approach to client care, the nurse should first assess the client who has diabetes and takes glipizide. - An adverse effect of glipizide is hypoglycemia and a blood glucose level of 68 mg/dL is below the expected reference range; therefore, this is the client the nurse should assess first.

Nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which is an appropriate action by the nurse manager? A) Ask other staff nurses about the level of care the specific staff nurse provides B) Address the concern with the specific staff nurse C) Recommend the specific staff nurse to be transferred to another unit D) Notify the human resources department about the request

B) Address the concern with the specific staff nurse - The nurse manager should use the conflict management skill collaborating to resolve the conflict. - The nurse manager should be assertive and ask the specific staff nurse about the problem.

Nurse on a ped unit is reviewing her client assignments following the shift report. Which client should the nurse plan to assess first? A) A school-age child who has diabetes mellitus and requires blood glucose monitoring B) An infant who has pertussis and is receiving oxygen via nasal cannula C) An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions D) A toddler who has both arms in casts and needs to be fed his breakfast

B) An infant who has pertussis and is receiving oxygen via nasal cannula - Using the ABC approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.

Client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? A) An expert nurse provides testimony that the nurse should have handled the situation differently B) Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation C) The client's attorney states that injury to the client could have been prevented D) The client's provider testifies the nurse was at fault for the injury

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

Nurse manager observes an unknown man in a lab coat making copies of a client's medical record. Which action should the nurse take first? A) Notify hospital security B) Approach the man and ask why he is making copies C) Inform the nurse supervisor D) Report the observation to the nurse caring for the client

B) 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.

Nurse is planning a community diabetes mellitus management program. Which goals should the nurse include for the program? A) Proper foot care will be demonstrated to clients during the program B) Clients will have a decreased incidence of foot amputations C) A facility will be reserved for the program D) Handouts and teaching materials will be distributed at the program

B) Clients will have a decreased incidence of foot amputations - A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program.

Nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client med. errors. Which methods should the nurse use to evaluate the success of the changes? A) Establish a benchmark to identify a standard of performance B) Compare the number of medication errors before and after the action was implemented C) Provide the staff with a questionnaire to quantify staff satisfaction with no changes D) Conduct a study about the time and money costs of implementing the change

B) Compare the number of medication errors before and after the action was implemented - Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions. - A benchmark measures the practices of an organization against a best-performing organization in order to develop improvement of performance. It is used as a tool to determine the desired standard of performance.

Nurse manager is preparing an in-service program for the nurses on the unit about the use of a new infusion pump. Which teaching strategies is the most effective way to ensure that the staff can use the device correctly? A) Provide a written procedure for the use of the device for the staff to review B) Demonstrate using the device and observe the staff returning the demonstration C) Remind the staff to review the procedure manual prior to using the new pump D) Identify the differences and new features of the device in a written brochure

B) Demonstrate using the device and observe the staff returning the demonstration

Nurse is caring for a group of clients. She plans to delegate obtaining morning vitals to an AP on her team. Which action should the nurse plan to take? A) Verify the AP's educational preparation prior to delegating the tasks B) Determine the time frame the AP should report the results C) Observe the AP as she obtains the vitals on each client D) Ask the AP to take the vitals of the client returning from surgery first

B) Determine the time frame the AP should report the results - The right communication is one of the five rights of delegation. - The nurse should communicate with the AP and provide direction as to when the AP should report the findings of the vital signs.

When planning delegation of tasks to AP, a nurse considers the 5 rights of delegation. Which should the nurse consider when using 1 of the 5 rights of delegation? A) The AP's ability to prioritize B) The AP has the knowledge and skill to perform the task C) The AP's rapport with clients D) The AP's ability to complete the task without assistance

B) The AP has the knowledge and skill to perform the task

Nurse on a med-surg unit is reconciling a newly admitted client's meds. The nurse is reviewing the process of medication reconciliation with a. new nurse. The nurse should include which info? A) The American Hospital Association requires accredited facilities to have protocols in place requiring med. reconciliation B) The purpose of medication reconciliation is to prevent adverse medication reactions C) The nurse who performs medication reconciliation is demonstrating ethical principal of veracity D) The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility

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

Nurse in a long-term care facility has assigned a task to an AP. The AP refuses to perform the task. Which is an appropriate statement for the nurse to make? A) "I feel you are being inconsiderate of the other team members" B) "I have to let the director of nursing know about this situation" C) "I need to talk to you about the unit policies regarding client assignments" D) "You always get your choice of assignments and don't work your fair share"

C) "I need to talk to you about the unit policies regarding client assignments" - This statement opens the conversation in a nonthreatening way and places the focus on the issue of policies rather than on any personal desire or characteristic of the individual.

Nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which statement by a newly licensed nurse indicates understanding of the teaching? A) "I should wait to empty my client's drainable colostomy until it is 3/4 full" B) "I should delegate providing closed irrigation to the AP" C) "I should encourage clients to receive an annual flu immunization" D) "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care"

C) "I should encourage clients to receive an annual flu immunization" - Cost containment is the delivery of effective and efficient care. - Cost is maintained without loss of quality. - The nurse should encourage clients to receive an annual flu immunization to prevent the need for treatment and hospitalization necessary with influenza.

Charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which statement by the charge nurse is appropriate? A) "You should think about how you make others feel when you lose your temper" B) "I will help you with this procedure instead of the staff nurse" C) "It must be very frustrating when you don't have what you need to perform the procedure" D) "If you let us know ahead of time that you plan to perform a procedure, we could do a better job having the supplies available"

C) "It must be very frustrating when you don't have what you need to perform the procedure" - The charge nurse is acknowledging the provider's frustration when making this statement. - This can lead to resolution of the conflict.

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which is an appropriate response by the nurse? A) "Let's talk about something else" B) "Whether or not I am a good lover is irrelevant" C) "Speaking to me like that makes me uncomfortable" D) "You need to lower your voice. Others can hear you"

C) "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.

Nurse manager is providing an in-service program about delegation to AP with staff nurses on the unit. Which statement by the staff nurse indicates an understanding of the teaching? A) "The nurse relinquishes accountability for client outcomes when care is delegated to an AP" B) "The AP can provide client education about how to perform basic self-care to client" C) "The nurse should consider the AP's level of experience when making delegation decisions" D) "The AP can re-delegate a task to another AP who has similar work experience"

C) "The nurse should consider the AP's level of experience when making delegation decisions"

Nurse is assigned a group of clients at the start of the shift. Which clients should the nurse plan to care for first? A) A client who needs assistance with a bath B) A client requesting a referral for home health services C) A client asking about his PCA pump that contains morphine D) A client who has questions about his new prescription

C) A client asking about his PCA pump that contains morphine - Clients who are administered morphine are at risk for respiratory distress. - When using the urgent vs. nonurgent approach to client care, this is the client the nurse should care for first.

Nurse is triaging clients following a mass casualty event. Which clients should the nurse assess first? A) A client who has a splinted open fracture of left medial malleolus B) A client who has a massive head injury and is experiencing seizures C) A client who has a severe respiratory stridor and a deviated trachea D) A client who has a small circular partial-thickness burn of the left calf

C) A client who has a severe respiratory stridor and a deviated trachea - A client who has severe respiratory stridor and a deviated trachea is unstable. - This client is triaged as emergent, and requires immediate attention to survive. - This client has manifestations of a tension pneumothorax and airway obstruction. - Therefore, this client is the highest priority for the nurse to assess.

An RN from the maternal-newborn unit is being floated to a med-surg unit. Which client should should charge nurse on the med-surg unit plan to assign to the RN? A) A client who has terminal end-stage renal diseaes B) A client who has acute pancreatitis C) A client who is 1-day post-op following a total abdominal hysterectomy D) A client who has a stroke and is to be admitted

C) A client who is 1-day post-op following a total abdominal hysterectomy - The nurse who floats to another unit must have the skills to provide safe care to clients. - This client is stable. - This is an appropriate assignment for the RN.

Nurse is caring for 4 post-op clients. The nurse can delegate obtaining vitals to an AP for which client? A) A client who is 1 hr post-op following a thyroidectomy B) A client who is 2 hr post-op following an abdominal hysterectomy C) A client who is 3 days post-op following gastric bypass surgery D) A client who is 3 days post-op following a craniotomy

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

Nurse is triaging clients in an urgent care clinic. Which clients should the nurse have the provider care for immediately? A) An adolescent female client who is belligerent and has slurred speech B) A toddler who has a laceration on his forehead and is screaming C) A middle adult male who is diaphoretic and reports epigastric pain D) A young adult with a painful sunburn on his face and arms

C) 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.

Nurse is triaging clients in the ER. Which client should the nurse ask the provider to care for first? A) A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min B) A toddler who has otitis media, a temperature of 39.2C (102.6F), and a purulent ear discharge C) A school-age child who has acute epiglottis, is drooling, and has an absence of spontaneous cough D) An adolescent who has sickle cell disease, reports a pain of 7 out of 10, and requests pain meds.

C) A school-age child who has acute epiglottis, is drooling, and has an absence of spontaneous cough

Charge nurse is delegating tasks to nursing personnel on a 10-bed med-surg nursing unit. Which assignment is an example of overdelegation? A) Assigning 2 AP to ambulate all clients B) Assigning a new grad nurse to perform a wet-to-dry dressing change C) Assigning the most efficient AP to perform glucometer monitoring for each client D) Assigning the most competent RN to perform central dressing change

C) 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.

Nurse is caring for an older adult client who is disoriented and has a history of falls. Which action should the nurse take? SATA A) Raise all side rails on the client's bed B) Obtain a prescription to restrain the client PRN C) Check on the client hourly D) Instruct the client in the use of the call light E) Apply an ambulation alarm to the client's leg

C) Check on the client hourly D) Instruct the client in the use of the call light E) Apply an ambulation alarm to the client's leg - Raising all side rails is considered a restraint. For a client who is disoriented, the risk for injury is greater with all side rails of the bed raised. If the client attempts to get out of bed, she may try to climb over the side rail or climb out at the foot of the bed. The nurse should place the bed in the lowest position. - Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach. - Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use. - The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.

Nurse is caring for a client on the med-surg unit. The client has been taking warfarin at home and her lab values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which action should the nurse take? A) Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form B) Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit C) Explain the risk the client faces if she leaves the facility D) Ask the security department to guard the room to the client's door

C) Explain the risk the client faces if she leaves the facility

Nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving meds. Which of the following actions should the nurse take first to resolve the conflict? A) Implement a resolution B) Brainstorm solutions C) Identify the problem D) Evaluate the results

C) Identify the problem - The first action the nurse should take using the nursing process is to assess the situation and identify the problem so that a solution is found.

Nurse is delegating client care assignments for the shift. Which tasks should the nurse delegate to an AP? A) Perform wound irrigation for a client B) Evaluate pain relief for a client following the administration of a pain med C) Measure and record I/O for a client D) Teach a client about low-sodium foods

C) Measure and record I/O for a client

Nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which tasks should the nurse assign to the AP? A) Application of antibiotic ointment to the arm of a client who has dermatitis B) Obtaining medical history information from a stable client who is being admitted C) Monitoring vitals of a client who had an appendectomy 12 hr ago D) Removal of the NG tube of a client who has been receiving enteral feedings

C) Monitoring vitals of a client who had an appendectomy 12 hr ago - Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an appropriate task for the AP because it does not involve assessment, specialized knowledge, or judgment.

A nurse is planning care for 4 clients and is assigning tasks to a LPN and AP. Which should the nurse assign to the LPN? A) Complete an admission assessment for a client who has COPD B) Measure I/O for a client who has an indwelling urinary catheter C) Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty D) Develop a plan of care for a client who has cholecystitis

C) Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty

An RN is making nursing staff assignments for his team consisting of himself, 2 LPNs, and an AP. Which clients should he assume responsibility for? A) The client who requires frequent ambulation B) The client who is in protective isolation C) The client who is actively dying and requires IV pain meds D) The client who is 3 days post-op and requires a dressing change

C) The client who is actively dying and requires IV pain meds - 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.

Nurse is participating in a disaster stimulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which activities would be the lowest priority to the nurse? A) Preventing cross-contamination of clients B) Performing concise client assessment C) Transferring a client to the discharge location D) Maintaining a client tracking system

C) Transferring a client to the discharge location - Nursing care in a disaster setting focuses on essential care. - The nurse should recognize non-skilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel.

Nurse is obtaining informed consent from a client who is pre-op. Which actions should the nurse take? SATA A) Establish that the client is able to pay for the surgical procedure B) Explain the surgical procedure to the client C) Validate the signature is authentic D) Verify the client understands the surgical procedure E) Confirm the consent is voluntary

C) Validate the signature is authentic D) Verify the client understands the surgical procedure E) Confirm the consent is voluntary

Charge nurse delegates a LPN the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which action should the nurse take? A) Change the client's dressing B) Reassign the task to another nurse C) Verify the LPN knows how to do a dressing change D) Report the issue to the unit manager

C) Verify the LPN knows how to do a dressing change - The charge nurse should attempt to see the delegated task from the perspective of the individual being delegated to. - This approach clarifies the reason for lack of action by the LPN.

While caring for a client, the nurse experiences a needle stick injury. Which action should the nurse take first? A) Complete an incident report B) Request the risk manager obtain consent for HIV testing from the client C) Wash the site of injury with soap and water D) Consent to post-exposure treatment with antiretroviral meds.

C) Wash the site of injury with soap and water - The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.

Nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which action? A) Discussing advance directives with the client and the client's family B) Providing comfort care measures to the client C) Withholding a dose of narcotic pain meds. when the client has respiratory depression D) Allowing the client's family unlimited visitation at the time of death

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

Nurse is caring for a client whose family member requests to view the client's medical record. Which response should the nurse make? A) "I will ask the nursing supervisor to obtain the medical records for you" B) "The health care provider will share this info. for you" C) "The ethics committee will need to approve this request for you" D) "The client must provide permission to share the records with you"

D) "The client must provide permission to share the records with you" - Client information is shared only with individuals involved directly in the client's care. - The client must provide permission for the family to access protected health information.

Nurse on the pediatric unit is providing room assignments for children who are to be admitted. The nurse should plan to place a child who is post-op from an appendectomy to which of the following clients? A) A child who is experiencing sickle cell crisis B) A child who has streptococcal pharyngitis C) A child who has a head injury D) A child who has a new diagnosis of type 1 diabetes mellitus

D) 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.

Nurse on an obstertic-gynecology unit is planning care for 4 clients after receiving change of shift report. Which client should the nurse assess first? A) A client who is 1 day postpartum after a late term miscarriage B) A client who had a bilateral tubal ligation 12 hr previously C) A client who is 4 days postpartum and has mastitis D) A client admitted 1 hr ago for an ectopic pregnancy

D) 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.

Nurse is caring for 4 clients who are post-op from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which clients is the nurse's priority? A) A client who has a prescription for insulin and his pre-meal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL B) Client whose wound drainage at 0800 was sanguineous and now it is serosanguineous C) A client who reports pain as 4 on a scale of 10 at 0800 and now reports pain as 6 D) A client whose BP at 0800 was 138/68 mmHg and at 1200 is 106/60 mmHg

D) A client whose BP at 0800 was 138/68 mmHg and at 1200 is 106/60 mmHg - A client who is postoperative is at risk for hemorrhage. - A blood pressure decrease of 15 to 20 points is significant. - This client is unstable; therefore, this client is the nurse's priority.

Nurse manager is preparing an in-service program about managing conflict for the nurses on the unit. The nurse manager should identify which examples as interpersonal conflict? A) Nurses on the unit disagree about what time of day daily client weighs should be obtained B) A nurse is uncertain about joining a professional nursing organization C) A nurse sho just lost his spouse does not want to be assigned to care for a terminally ill client D) An experienced nurse is uncivil to a newly licensed nurse

D) 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.

Nurse asks an AP to take a specimen to the lab and the AP refuses. Which action should the nurse take? A) Take the specimen to the lab B) Report the AP to the charge nurse C) Complete an incident report D) Ask the AP about her concerns with the assignment

D) Ask the AP about her concerns with the assignment - Reviewing the incident with the AP allows the nurse to understand the delegated task from the AP's perspective. - The nurse should attempt to determine the underlying problem the AP has with the assignment.

Nurse is working with an AP to care for a group of clients on the pediatric unit. Which tasks should the nurse have the AP perform first? A) Collect a stool sample for ova and parasites from a school-age child B) Engage a toddler in play C) Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for treatment of Hodgkin lymphoma D) Check to see if the elbow restraint is in place for an infant who is post-op from a surgical correction of a celt palate

D) Check to see if the elbow restraint is in place for an infant who is post-op from a surgical correction of a celt palate - The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first.

Charge nurse allows 2 nurses who are arguing about who gets to go to lunch first go together. The charge nurse agrees to take care of both nurses' clients while they're at lunch. Charge nurse is demonstrating which types of conflict management? A) Avoiding B) Competing C) Compromising D) Cooperating

D) Cooperating - The charge nurse displayed cooperating, which is the resolution of the conflict by sacrificing. - In this situation, it allowed both staff nurses to get what they wanted.

Nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his meds. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of? A) Slander B) Invasion of privacy C) Defamation of character D) False imprisonment

D) False imprisonment - Unlawfully restraining a client is false imprisonment. - Clients have the right to refuse treatment.

At the beginning of the shift, an RN is preparing assignments for a LPN and AP. Which tasks should the nurse assign to the LPN? A) Providing postmortem care for a client B) Measuring the client's I/O C) Obtaining a client's weight D) Inserting a NG tube for a client

D) Inserting a NG tube for a client

Nurse is providing care for a surgeon on a med-surg unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide that info. requested. The nurse is displaying which of the following ethical principles? A) Utility B) Paternalism C) Justice D) Nonmaleficence

D) 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. - Justice is the ethical principled based on the belief that everyone should be treated fairly.

Nurse is discussing emergency response with a new nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? A) Members of the Federal Emergency Management Agency (FEMA) B) Responding law enforcement officers C) Representatives from the American Red Cross D) Nurses and other emergency medical personnel

D) Nurses and other emergency medical personnel - Nurses and other emergency personnel such as physicians, EMTs, and paramedics are responsible for performing triage duties.

Nurse on a med-surg unit is planning to delegate tasks to an adult volunteer. Which tasks should the charge nurse avoid assigning to the volunteer? A) Delivering meal trays to clients in their rooms B) Assisting a client who has difficulty seeing the foods on the tray while eating C) Delivering routine urine specimen to the lab D) Observing a post-op client who is confused

D) Observing a post-op client who is confused - A nurse who uses delegation is responsible for delegating tasks to the right person. - A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. - The observation of this client should be assigned to a member of the nursing staff.

Charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which action should the nurse take? A) Inform the staff member of her appraisal for that day prior to change-of-shift report B) Schedule the appraisal interview as early in the shift as possible C) Provide a chair directly across the desk for the staff member to sit in D) Provide the staff member with a copy of the appraisal form in advance

D) Provide the staff member with a copy of the appraisal form in advance - The charge nurse should ensure the staff member knows the standards by which her work will be evaluated and that she has a copy of the appraisal form.

Nurse s preparing an in-service for an annual skills at a community medical facility about fire safety. Place the steps in order in which they should be performed in care of a fire emergency. A) Pull the fire alarm B) Confine the fire C) Extinguish the fire D) Rescue the clients

D) Rescue the clients A) Pull the fire alarm B) Confine the fire C) Extinguish the fire - Following the RACE mnemonic the nurse should first rescue all clients by moving them to a safe area out of immediate danger. - Next the nurse should pull the alarm fire and then, if possible, call the agencies emergency extension to report the location and details of the fire. - The next step the nurse should take is to close all of the room doors and fire doors at the entrance to the unit to confine the fire. - Lastly, the nurse should attempt to extinguish the fire with the appropriate fire extinguisher. - If unable to do so, the nurse should evacuate the area.

Home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which referral should the nurse plan to make? A) Hospice care B) Restorative care C) Mental health care D) Respite care

D) Respite care