NUR280 ATI Leadership and Management Review
"I will make sure the monitor is turned off when I have to leave the computer terminal." "I can share my password with nursing students assigned to my unit." "I will allow the client to make changes directly to his medical record." "After I finish with the printout of my assignment, I'll put it in the shredder receptacle."
"I will make sure the monitor is turned off when I have to leave the computer terminal." The nurse should log off the computer when leaving the terminal so that no one else can activate the screen and access clients' protected health information. "I can share my password with nursing students assigned to my unit." The nurse should not share her password to maintain client confidentiality. "I will allow the client to make changes directly to his medical record." The nurse should notify the charge nurse if a client requests an amendment to the medical record. "After I finish with the printout of my assignment, I'll put it in the shredder receptacle." MY ANSWER The nurse should shred all computer printouts and worksheets that contain clients' protected health information to maintain client confidentiality.
"I'm not sure whether I want to apply for the unit manager's position or start a family this year." "I feel frustrated because I just readmitted a client who refuses to take his insulin." "The unit manager is more concerned with saving money than with clients getting quality care." "Every time I request an extra day off I'm denied, but other nurses' requests are approved."
"I'm not sure whether I want to apply for the unit manager's position or start a family this year." MY ANSWER The nurse's statement indicates an intrapersonal conflict because the nurse is struggling with competing personal and professional values and desires. "I feel frustrated because I just readmitted a client who refuses to take his insulin." The nurse's statement illustrates an interpersonal conflict with a client. "The unit manager is more concerned with saving money than with clients getting quality care." The nurse's statement illustrates an interpersonal conflict with the nurse manager. "Every time I request an extra day off I'm denied, but other nurses' requests are approved." The nurse's statement illustrates an interpersonal conflict with a nurse manager.
Please take the vital signs of the clients in rooms 200 through 208." "Obtain the weight of the client in room 202 using the bed scales." "Tell me what time the client in room 205 voids for the first time after his catheter is removed." "The client in room 201 needs to have antiembolic stockings applied."
"Please take the vital signs of the clients in rooms 200 through 208." The nurse should indicate to the AP the time to obtain the client vital signs and to report the findings back to the nurse. "Obtain the weight of the client in room 202 using the bed scales." The nurse should indicate to the AP to obtain the client's weight before breakfast and report the finding back to the nurse. ***"Tell me what time the client in room 205 voids for the first time after his catheter is removed." The nurse is using the five rights of delegation by providing specific information about the task, expectation, timeframe, and when to report the information back to the nurse. "The client in room 201 needs to have antiembolic stockings applied." The nurse should indicate to the AP the size, purpose, and time to apply the antiembolic stockings.
"Would you accept the assignment if we reassign your client who has total care needs and assign another client who can provide more self-care?" "Tell me what changes we need to make so that you'll feel comfortable with the assignment." "I didn't mean to make you feel overwhelmed. Why don't you look over the assignments with me and suggest changes?" "You always complete your work on time and do a great job. I believe you can handle the assignment well."
"Would you accept the assignment if we reassign your client who has total care needs and assign another client who can provide more self-care?" The charge nurse uses compromise by giving up a demand while asking the staff nurse also to give up a demand. "Tell me what changes we need to make so that you'll feel comfortable with the assignment." The charge nurse uses cooperation by giving up her own desires for the desires of the staff nurse. "I didn't mean to make you feel overwhelmed. Why don't you look over the assignments with me and suggest changes?" The charge nurse uses collaboration by putting aside individual desires and focusing on shared decision making. "You always complete your work on time and do a great job. I believe you can handle the assignment well." MY ANSWER The charge nurse is using smoothing as a conflict resolution strategy by complimenting or focusing on shared ideas to reduce the emotional component of the conflict.
"I delegate tasks to personnel based on their job descriptions." "Everyone working here has to care for clients who are incontinent." "Let's talk about organizing the workflow so you care for fewer of these clients." "Why do you not want to care for clients who are incontinent?"
***"I delegate tasks to personnel based on their job descriptions." This response addresses the AP's concerns and provides clear information about the charge nurse's responsibility when delegating tasks. "Everyone working here has to care for clients who are incontinent." This response is nontherapeutic because it is dismissive of the AP's concerns. "Let's talk about organizing the workflow so you care for fewer of these clients." This response is inappropriate because the AP does not have the knowledge, skills, and ability to assist with client assignments. "Why do you not want to care for clients who are incontinent?" Asking the AP why she does not want to care for clients who are incontinent is a nontherapeutic response that can make the AP feel defensive.
Mop the floors with a bleach solution. Clean the floors with a chlorhexidine solution. Soak the linens in hot water prior to washing. Double-bag the linens in biohazard bags.
***Mop the floors with a bleach solution. Personnel should use bleach to clean a blood spill because bleach is a disinfectant agent that kills bloodborne pathogens. Clean the floors with a chlorhexidine solution. Personnel should use chlorhexidine gluconate to clean the client's skin rather than the floor. Soak the linens in hot water prior to washing. Soaking the linens in hot water can cause the protein in the blood to coagulate and adhere to the linens. Double-bag the linens in biohazard bags. Personnel can place items contaminated with blood in a single bag.
Perform chest compressions on a client who is in cardiac arrest. Change a sterile dressing on a client's central line. Check the residual of a client's gastrostomy tube. Educate a client about the use of an inhaler.
***Perform chest compressions on a client who is in cardiac arrest. The nurse should assign an AP to perform chest compressions on a client who is in cardiac arrest. Performing basic CPR is within the AP's scope of practice. Change a sterile dressing on a client's central line. A sterile dressing change on a client's central line requires the knowledge and skill of a professional nurse; therefore, the nurse should not delegate this task to an AP. Check the residual of a client's gastrostomy tube. Checking the residual of a client's gastrostomy tube requires the knowledge and skill of a professional nurse; therefore, the nurse should not delegate this task to an AP. Educate a client about the use of an inhaler. Educating a client on the use of an inhaler requires the knowledge and skill of a professional nurse; therefore, the nurse should not delegate this task to an AP.
A client who has COPD and an oxygen saturation of 90% A client who has a potassium level of 6.5 mEq/L A client who had surgery 1 day ago and requests pain medication A client who has diabetes mellitus and a fasting blood sugar of 135 mg/dL
A client who has COPD and an oxygen saturation of 90% COPD is a chronic disorder and an oxygen saturation of 90% is an expected finding; therefore, there is another client the nurse should assess first. A client who has a potassium level of 6.5 mEq/L MY ANSWER When using the acute vs chronic approach to client care, the nurse should first assess the client who is at risk for cardiac dysrhythmias; therefore, the nurse should assess the client who has a potassium level of 6.5 mEq/L which indicates hyperkalemia. Cardiac complications of hyperkalemia can include bradycardia, hypotension, complete heart block, and can lead to asystole. A client who had surgery 1 day ago and requests pain medication A client who is 1 day postoperative and has pain is an expected finding; therefore, there is another client the nurse should assess first. A client who has diabetes mellitus and a fasting blood sugar of 135 mg/dL Diabetes mellitus is a chronic disorder and a fasting blood sugar of 135 mg/dL is an expected finding; therefore, there is another client the nurse should assess first.
A client who has a closed leg fracture and reports peripheral paresthesia A client who reports a sprained ankle and has a laceration over the medial ankle A client who has arm contusions and manifests asymmetrical thoracic movement A client who has abrasions to the face and is requesting medication for severe pain
A client who has a closed leg fracture and reports peripheral paresthesia A client who has a closed leg fracture does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first. Although the client could have neurological or circulatory complications, another client has a more urgent need. A client who reports a sprained ankle and has a laceration over the medial ankle A client who reports a sprained ankle and has a laceration does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first. A client who has arm contusions and manifests asymmetrical thoracic movement MY ANSWER A client who has asymmetry of the thorax likely has a tension pneumothorax and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should request the provider to assess this client first. A client who has abrasions to the face and is requesting medication for severe pain A client who has abrasions to the face and is requesting medication for severe pain does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first.
A client who is in balanced skeletal traction A client who had a total hip arthroplasty 3 days ago A client who has a fractured femur with a new cast A client who had a right above-the-knee amputation 24 hr ago
A client who is in balanced skeletal traction An orthopedic nurse should care for this client because he has experiential knowledge of the care of balanced skeletal traction required to safely care for this client. A client who had a total hip arthroplasty 3 days ago An orthopedic nurse should care for this client because he has experiential knowledge of the postoperative restrictions for hip arthroplasty required to safely care for this client. A client who has a fractured femur with a new cast An orthopedic nurse should care for this client because he has experiential knowledge of the care of a new cast and monitoring required to safely care for this client. A client who had a right above-the-knee amputation 24 hr ago MY ANSWER A nurse from a medical unit can care for this client because the surgical dressing is usually left in place for 48 to 72 hr, so the residual limb does not require special care at this time.
A client who is scheduled for a tubal ligation in 2 hr and is crying A client who has peripheral vascular disease and has an absent pulse in the right foot A client who has type 1 diabetes mellitus and needs the first dressing change for a stage II decubitus ulcer A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (100.4° F)
A client who is scheduled for a tubal ligation in 2 hr and is crying The nurse should assess this client to determine why she is crying; however, this is not the nurse's priority finding. A client who has peripheral vascular disease and has an absent pulse in the right foot MY ANSWER When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is an absent pulse, which indicates no blood flow to the extremity. A client who has type 1 diabetes mellitus and needs the first dressing change for a stage II decubitus ulcer The nurse should change this client's dressing to promote adequate wound healing; however, this is not the nurse's priority. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (100.4° F) The nurse should implement measures to reduce client's temperature; however, this is not the nurse's priority.
An office chair with wheels at the client's computer desk An oxygen tank standing on the floor next to the client's recliner A raised vinyl seat on the toilet in the client's bathroom A family member smoking on the front porch of the client's home A throw rug over vinyl flooring in the client's bathroom
An office chair with wheels at the client's computer desk is correct. Wheeled chairs create a safety hazard for the client because he may fall while sitting and rising from the chair, especially while managing oxygen equipment. An oxygen tank standing on the floor next to the client's recliner is correct. The client should always keep the oxygen tank in a rack or stand. Otherwise, it is easy to knock it over and risk sudden decompression and uncontrolled movement of the tank, which could cause injury. A raised vinyl seat on the toilet in the client's bathroom is incorrect. A raised toilet seat decreases the client's risk for injury, as it makes it easier to sit and rise without straining joints and risking instability, especially while managing oxygen equipment. A family member smoking on the front porch of the client's home is incorrect. No one should smoke inside the home when oxygen is in use. The safest approach is to ask all smokers to step outside when they smoke. A throw rug over vinyl flooring in the client's bathroom is correct. Covering flooring with a throw rug can increase the client's risk for falls.
An older adult client who has facial drooping following a stroke 2 days ago An adult client who has a femur fracture reports feeling short of breath A school-age child who had an appendectomy last night is crying because of pain An adult client who has a T-tube has 300 mL of greenish-brown drainage over 12 hr
An older adult client who has facial drooping following a stroke 2 days ago Facial drooping is nonurgent because it is an expected finding for a client following a cerebrovascular accident; therefore, there is another finding that is the priority. An adult client who has a femur fracture reports feeling short of breath MY ANSWER When using the urgent vs nonurgent approach to client care, the nurse determines that the priority finding is an adult client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep venous thrombosis, which can lead to pulmonary embolism. A school-age child who had an appendectomy last night is crying because of pain Presence of pain is nonurgent because it is an expected finding for a client following surgery; therefore, there is another finding that is the priority. An adult client who has a T-tube has 300 mL of greenish-brown drainage over 12 hr Greenish-brown drainage from a T-tube is nonurgent because it is an expected finding for a client following cholecystectomy; therefore, there is another finding that is the priority.
Apply a piece of electrical tape over the fray. Place the pump in the hallway outside the client's room. Check to see if the pump is still working. Report the pump with the frayed cord to the maintenance department.
Apply a piece of electrical tape over the fray. Applying a piece of tape over the frayed cord increases the risk for electrical shock. The nurse should not use equipment that appears to be damaged. Place the pump in the hallway outside the client's room. A different staff member could retrieve the pump with the frayed cord from the hallway and use it in another client's room. Check to see if the pump is still working. Checking to see if the pump is still working could cause harm to the nurse or client. Report the pump with the frayed cord to the maintenance department. MY ANSWER The nurse should remove the infusion pump from the client's room and report a fraying cord to the department responsible for equipment maintenance and repair.
Ask the client to report if the aquathermia pad gets too warm. Check the client's leg 30 min after applying the aquathermia pad. Show the client where the power button is located. Ensure that the client's call light is in reach. Decrease the temperature by 5° if the client's skin becomes reddened.
Ask the client to report if the aquathermia pad gets too warm is correct. The nurse should instruct the client and family to report if the aquathermia pad gets too warm to prevent client injury. Check the client's leg 30 min after applying the aquathermia pad is incorrect. The nurse should check the client's right lower leg within 15 to 20 min of applying the aquathermia pad to ensure there is no evidence of complications. Show the client where the power button is located is correct. The nurse should show the client where the power button is located so that he can control the equipment himself. Ensure that the client's call light is in reach is correct. The nurse should ensure that the client's call light is in reach as part of basic safety instructions. Decrease the temperature by 5° if the client's skin becomes reddened is incorrect. The nurse should monitor the client's skin for increased redness and should discontinue the aquathermia pad if it is noted. The nurse should report the finding to the provider.
Assess the client's home environment for possible reservoirs of infection. Verify the patency of the PICC line. Provide dressing change and wound assessment teaching. Ensure that home infusion therapy has been arranged.
Assess the client's home environment for possible reservoirs of infection. The home health nurse caring for the client has the responsibility to assess the client's home environment. Verify the patency of the PICC line. The nurse who is discharging the client has the responsibility to verify the patency of the PICC line. Provide dressing change and wound assessment teaching. The nurse who is discharging the client provides dressing change and wound assessment teaching to the client. Ensure that home infusion therapy has been arranged. MY ANSWER It is the case manager's responsibility to ensure that all necessary referrals have been made to facilitate the client's transition to home care.
Assign client care to staff. Coordinate staff breaks. Organize daily meetings using an appointment book. Review long-term goals of the unit.
Assign client care to staff. MY ANSWER When using the urgent vs nonurgent approach to client care, the nurse determines that the priority action is to assign client care to staff. This ensures continuity of care and that clients receive prescribed treatments in a timely manner. Coordinate staff breaks. Coordinating staff breaks is nonurgent; therefore, another action is the nurse's priority. Organize daily meetings using an appointment book. Organizing daily meetings using an appointment book is nonurgent; therefore, another action is the nurse's priority. Review long-term goals of the unit. Reviewing short- and long-term goals of the unit is nonurgent; therefore, another action is the nurse's priority.
Assign two clients who have had a stem cell transplant to the same room. Obtain a rectal temperature on clients every 4 hr. Wear an N95 respirator mask while caring for these clients. Place clients in positive-pressure airflow rooms.
Assign two clients who have had a stem cell transplant to the same room. The nurse should only cohort two clients in a semi-private room if they are infected with the same pathogen. The nurse should assign clients who have had a stem cell transplant in private rooms to reduce the risk of infection. Obtain a rectal temperature on clients every 4 hr. The nurse should choose another route for measuring temperature to avoid introducing microorganisms that can cause an infection. Wear an N95 respirator mask while caring for these clients. Health care personnel should wear an N95 respirator mask while caring for clients who require airborne precautions. These masks protect the nurse from inhaling contaminated droplet nuclei. Place clients in positive-pressure airflow rooms. MY ANSWER The nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour.
Assist clients who are in immediate danger to a safe location. Close doors and windows on the unit. Attempt to extinguish the fire using an ABC fire extinguisher. Discontinue oxygen use for clients who can breathe without it.
Assist clients who are in immediate danger to a safe location. MY ANSWER The greatest risk to clients is injury from the fire. Therefore, the first action the nurse should take is to move clients who are in immediate danger to a safe location. Close doors and windows on the unit. The nurse should close the doors and windows on the unit to prevent the fire from spreading, but there is another action the nurse should take first. Attempt to extinguish the fire using an ABC fire extinguisher. The nurse should attempt to extinguish the fire using a universal fire extinguisher, but there is another action the nurse should take first. Discontinue oxygen use for clients who can breathe without it. The nurse should discontinue oxygen for clients who can breathe without it to prevent spread of the fire, but there is another action the nurse should take first.
Check the client's last INR. Notify the client's provider. Notify the risk manager. Complete an incident report.
Check the client's last INR. MY ANSWER The first action that the nurse should take using the nursing process is to assess the client. A client prescribed an anticoagulant who has missed several doses is at risk for thrombosis; therefore, the nurse should check the client's last INR to determine the client's coagulation status. Notify the client's provider. The nurse should notify the client's provider that the medication was not administered in case the provider needs to revise the treatment plan; however, there is another action the nurse should take first. Notify the risk manager. The nurse should notify risk management of the omitted medication to facilitate quality improvement; however, there is another action the nurse should take first. Complete an incident report. The nurse should complete an incident report when a medication error occurs; however, there is another action the nurse should take first.
Closed the door to the client's room Initiated the fire alarm system Transported the client to the hallway Attempted to extinguish the fire
Closed the door to the client's room The nurse should close the door to the client's room to confine the fire; however, according to the RACE protocol, this is not the first action the nurse should take. Initiated the fire alarm system The nurse should activate the fire alarm system to acquire additional help; however, according to the RACE protocol, this is not the first action the nurse should take. Transported the client to the hallway MY ANSWER The greatest risk to this client is injury from a fire; therefore, the first action the nurse should take using the RACE protocol is to remove the client from the area of danger. Attempted to extinguish the fire The nurse should attempt to extinguish the fire using a fire extinguisher appropriate to the type of fire; however, according to the RACE protocol, this is not the first action the nurse should take.
Conduct an in-service that reviews proper catheter insertion and maintenance. Perform a chart review to gather data about the clients who developed infections. Observe each staff nurse perform a urinary catheter insertion. Require completion of a self-paced instruction program.
Conduct an in-service that reviews proper catheter insertion and maintenance. The nurse manager should conduct an in-service to reinforce correct catheter procedure to prevent future incidences of urinary tract infections; however, there is another action the nurse manager should take first. Perform a chart review to gather data about the clients who developed infections. MY ANSWER The first action the nurse manager should take when using the nursing process is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection. Observe each staff nurse perform a urinary catheter insertion. The nurse manager should observe each staff nurse performing a urinary catheter insertion and provide correction when needed to ensure appropriate technique is used; however, there is another action the nurse manager should take first. Require completion of a self-paced instruction program. The nurse manager should require the nurses to complete a self-paced instruction program to reinforce correct catheter procedure; however, there is another action the nurse manager should take first.
Continue to attempt to contact the provider. Notify the nursing supervisor. Administer an emergency dose of potassium. Consult with the pharmacist.
Continue to attempt to contact the provider. This potassium level is critical and requires immediate attention. Continuing to attempt to contact the provider, who has not responded to pages for 1 hr, does not address the urgency of the situation. Notify the nursing supervisor. MY ANSWER This potassium level is critical and requires attention. The nurse should notify the nursing supervisor that the provider has not responded to pages, and steps should be taken to ensure the standard of care. Administer an emergency dose of potassium. Nurses need a prescription to administer a medication such as potassium. Consult with the pharmacist. Pharmacists employed in inpatient settings do not usually prescribe medications for clients.
Daily activity schedule Treatments that have been discontinued List of current medications Laboratory reports for the past 3 months
Daily activity schedule The resident's daily activity schedule is not relevant information about the resident's current condition; therefore, the nurse should not include this data in the transfer paperwork. Treatments that have been discontinued The nurse should include treatments that the resident should continue as well as any restrictions on activity in the transfer paperwork. List of current medications MY ANSWER The nurse should include the resident's current list of medications to maintain safe and effective delivery of care. Laboratory reports for the past 3 months The laboratory reports for the resident from the past 3 months are not relevant to the resident's current condition. Current laboratory findings can be helpful to the staff caring for the resident and his current condition.
Leave the medication on the client's bedside table to take later. Return in 1 hr to administer the medication. Mix the medication in applesauce to administer to the client. Inform the client of the consequences of refusing the medication.
Leave the medication on the client's bedside table to take later. The nurse should not leave the medication on the client's bedside table because it is a safety risk to the client and others. If a client refuses medication, the nurse should discard the medication according to facility protocol. Return in 1 hr to administer the medication. The client has refused the medication; therefore, the nurse should not return 1 hr later to make another attempt to administer the medication. Mix the medication in applesauce to administer to the client. The nurse should not administer medication to the client without the client's consent, as this disregards the client's right to self-determination. Inform the client of the consequences of refusing the medication. MY ANSWER The nurse should inform the client of the consequences of refusing the medication. It is the client's right to decide whether to take the medication. If the client still refuses after receiving further information, the nurse should waste the medication and document the occurrence in the client's medical record.
Notify the charge nurse of the client's request for transfer. Assure the client that staff involved in his care will be notified of his concern. Tell the client that future calls will be answered in a timely manner. Ask the client to verbalize his expectations.
Notify the charge nurse of the client's request for transfer. The nurse should notify the charge nurse of the client's request to advocate for the client, but this is not the first action the nurse should take. Assure the client that staff involved in his care will be notified of his concern. The nurse should assure the client that appropriate action will occur to demonstrate caring, but this is not the first action the nurse should take. Tell the client that future calls will be answered in a timely manner. The nurse should assure the client that in the future the nurses will answer his calls in a timely manner to demonstrate caring, but this is not the first action the nurse should take. Ask the client to verbalize his expectations. MY ANSWER The first action the nurse should take using the nursing process is to assess; therefore, the first action the nurse should take is to assess the client's feelings and clarify his expectations.
Opens the top flap of the sterile package toward herself Maintains a 1.25 cm (½ in) border around the edges of the sterile field Picks up first sterile glove by grasping the folded cuff edge Removes soiled dressings using sterile gloves
Opens the top flap of the sterile package toward herself The nurse should open the top flap of the sterile package away from her body. Maintains a 1.25 cm (½ in) border around the edges of the sterile field The nurse should maintain a 2.5 cm (1 in) border around the edges of the sterile field. Picks up first sterile glove by grasping the folded cuff edge MY ANSWER The nurse should pick up the first sterile glove by grasping the folded cuff edge, which is the palmar side, to prevent contamination of the outside of the glove. Removes soiled dressings using sterile gloves The nurse should use clean gloves to remove soiled dressings.
Perform the wound irrigation himself during rounds. Delegate the procedure to an assistive personnel (AP). Assign the procedure to a licensed practical nurse (LPN). Reschedule the procedure to be performed once daily.
Perform the wound irrigation himself during rounds. This is not an appropriate delegation of tasks. Delegate the procedure to an assistive personnel (AP). It is not within the AP's scope of practice to perform the wound irrigation. Assign the procedure to a licensed practical nurse (LPN). MY ANSWER This task is within the scope of practice of an LPN. The charge nurse should delegate this task to the LPN. Reschedule the procedure to be performed once daily. It is not within the scope of practice for the RN to change the prescription and this could affect the client's ability to heal.
A nurse manager confronts a nurse with smell of alcohol on her breath. which action to take?
Provide a series of counseling sessions with the nurse. The nurse manager is not responsible for taking on the role of counselor or treatment provider for an impaired nurse. Talk with the nurse's coworkers to determine a potential cause for the impairment. The nurse manager should not discuss the nurse's situation with coworkers nor diagnose a cause for the impairment. The nurse manager should handle the incident in a confidential manner. ***Set up a formal meeting with the nurse within 24 hr. Once the nurse manager has removed the nurse from the work environment and arranged for safe transportation home, the nurse manager should arrange to meet with the nurse within the next 24 hours. The nurse manager is to confront the nurse who was chemically impaired and clearly identify the facility's expectations. Report the nurse's chemical impairment to the risk manager. Impaired employees are not reported to risk management. The nurse manager should outline the rehabilitation measures for the nurse who is chemically impaired.
Raise the footplates of the wheelchair before transferring the client. Lock the brake on one wheel of the chair when transferring the client. Push the wheelchair into the elevator with the front wheels first. Stand behind the wheelchair when moving a client down a ramp.
Raise the footplates of the wheelchair before transferring the client. MY ANSWER The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury. Lock the brake on one wheel of the chair when transferring the client. The nurse should lock the brakes on both wheels when transferring the client. Push the wheelchair into the elevator with the front wheels first. The nurse should back the wheelchair into the elevator with the rear wheels first to prevent injury. Stand behind the wheelchair when moving a client down a ramp. The nurse should stand between the wheelchair and the bottom of the incline to provide better control of the wheelchair by keeping weight close to the body. This position allows the nurse to use the arms and legs rather than the back, which will prevent injury.
Recheck the client's blood pressure. Treat the client's blood pressure with a prescribed antihypertensive. Ask the LPN to review the technique for obtaining blood pressure. Review the client's medical record for other episodes of elevated blood pressure.
Recheck the client's blood pressure. MY ANSWER The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should recheck the client's blood pressure after 1 to 2 min to confirm the reading. Treat the client's blood pressure with a prescribed antihypertensive. The nurse may need to administer a prescribed antihypertensive to treat the client's blood pressure; however, there is another action the nurse should take first. Ask the LPN to review the technique for obtaining blood pressure. The nurse might need to ask the LPN to review the technique for obtaining blood pressure to ensure he knows how to do the procedure; however, there is another action the nurse should take first. Review the client's medical record for other episodes of elevated blood pressure. The nurse should review the client's medical record for other episodes of elevated blood pressure to identify a trend; however, there is another action the nurse should take first.
Request crutches from a medical equipment provider. Advise the client to install grab bars in her bathroom at home. Encourage the client to allow a home care aide to perform ADLs for her. Contact hospice to provide follow-up care for the client.
Request crutches from a medical equipment provider. A client who has left-sided weakness is at risk for falls and should not use crutches. The nurse should request a walker to assist the client with ambulation and promote independence. Advise the client to install grab bars in her bathroom at home. MY ANSWER The nurse should advise the client to install grab bars in her bathroom to reduce the risk for falls. Encourage the client to allow a home care aide to perform ADLs for her. Encouraging the client to allow the home care aide to perform her ADLs discourages her independence. Contact hospice to provide follow-up care for the client. A client who has left-sided weakness does not require hospice care. Hospice care is for clients who have a terminal illness.
Respiratory syncytial virus (RSV) Methicillin-resistant Staphylococcus aureus (MRSA) Clostridium difficile Chlamydia trachomatis
Respiratory syncytial virus (RSV) According to the Centers for Disease Control and Prevention, RSV is not a nationally notifiable infectious disease. Methicillin-resistant Staphylococcus aureus (MRSA) According to the Centers for Disease Control and Prevention, MRSA is not a nationally notifiable infectious disease. Clostridium difficile According to the Centers for Disease Control and Prevention, C. difficile is not a nationally notifiable infectious disease. Chlamydia trachomatis MY ANSWER According to the Centers for Disease Control and Prevention, chlamydia trachomatis is a nationally notifiable infectious disease in all 51 jurisdictions. The nurse should notify the state health department, which monitors and controls communicable diseases.
Respiratory therapy Social services Dietary services Occupational therapy
Respiratory therapy The client does not exhibit difficulty with her airway, lungs, or breathing; therefore, a referral for respiratory therapy is not needed. Social services The client does not describe problems with financial or domestic issues; therefore, a referral for social services is not needed. Dietary services The client does not report problems with her diet; therefore, a referral for dietary services is not needed. Occupational therapy MY ANSWER The nurse should recommend occupational therapy for a client who has osteoarthritis and reports difficulty with activities of daily living. Occupational therapy can assist the client with exercises to help the client complete these tasks.
Role model a positive approach to the changes. Redirect the conversation when staff members make negative comments about the changes. Encourage staff members who support the changes to discuss the issue with resistant staff. Suggest that resistant staff members transfer to a different unit. Reprimand staff members who are resistant to the changes.
Role model a positive approach to the changes is correct. It is important for the charge nurse to role model positive behaviors and demonstrate support of the change. Redirect the conversation when staff members make negative comments about the changes is incorrect. The charge nurse should give staff members who oppose the change the opportunity to verbalize their objections and thereby discuss possible solutions. Encourage staff members who support the changes to discuss the issue with resistant staff is correct. Peers can serve as change agents and encourage others to embrace the changes. Suggest that resistant staff members transfer to a different unit is incorrect. This approach avoids conflict rather than attempting to resolve it. Reprimand staff members who are resistant to the changes is incorrect. Resistance to change is a normal part of the change process. The charge nurse should use positive strategies to aid in acceptance of the proposed change.
Show the AP how to remove an indwelling urinary catheter. Review the AP's skill competency checklist. Ask the AP if she knows how to remove an indwelling urinary catheter. Pair the newly hired AP with an experienced AP.
Show the AP how to remove an indwelling urinary catheter. Showing an AP how to perform a skill does not ensure the AP is competent to perform the task. ***Review the AP's skill competency checklist. A review of the AP's checklist should validate that she has demonstrated the ability to safely perform the procedure. Ask the AP if she knows how to remove an indwelling urinary catheter. Asking an AP if she can perform the task does not provide evidence that she is competent to perform this skill. Pair the newly hired AP with an experienced AP. Pairing the newly hired AP with an experienced AP does not provide evidence that she is competent to perform this skill.
The age of the client The availability of community support groups The length of the client's stay The type of insurance the client carries
The age of the client The client's age is not a component of the clinical pathway and does not assist the nurse in evaluating cost effectiveness of health care. The availability of community support groups Availability of community support groups is not a component of the clinical pathway and does not assist the nurse in evaluating cost effectiveness of health care. The length of the client's stay MY ANSWER The client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten length of stay. The type of insurance the client carries The type of medical insurance the client carries is not a factor in determining cost-effective care.
Verify that the client understands the risks of the surgery. Ask the client to explain the procedure that is being performed. Answer the client's questions about the outcomes of the surgery. Determine if the client understands the benefits of the procedure.
Verify that the client understands the risks of the surgery. It is the responsibility of the provider to ensure the client has all necessary information about the risks of the surgery in order to make an informed decision and provide consent. ***Ask the client to explain the procedure that is being performed. The nurse should ask the client to explain the procedure that is being performed. This allows the nurse to verify the client's understanding of the information provided by the provider prior to witnessing the client's signature on the consent form. Answer the client's questions about the outcomes of the surgery. It is the responsibility of the provider to ensure the client has all necessary information about the outcomes of the surgery in order to make an informed decision and provide consent. Determine if the client understands the benefits of the procedure. It is the responsibility of the provider to ensure the client has all necessary information about the benefits of the surgery in order to make an informed decision and provide consent.
"Let's talk about the benefits of each treatment." "You should ask your provider to choose the best treatment for you." "Why don't you ask your partner for advice?" "I would choose the least invasive treatment if I were you."
"Let's talk about the benefits of each treatment." MY ANSWER Talking about the benefits of each treatment option supports the right of the client to make decisions regarding her treatment and encourages comparison of the treatments. "You should ask your provider to choose the best treatment for you." Telling the client to have her provider choose her treatment removes the client from the decision-making process. "Why don't you ask your partner for advice?" Asking "why" questions implies criticizing of the client and can make the client feel defensive. Encouraging the client to ask her partner what she should do removes the client from the decision-making process. "I would choose the least invasive treatment if I were you." Telling the client what she should do is offering advice, which assumes the nurse knows what is best for the client.
"I cannot make changes to my advance directive once the document is final." "This means I have outlined my wishes for medication treatment." "My partner will need to be present if I become unresponsive." "My provider will make my health care decisions if I am unable."
"I cannot make changes to my advance directive once the document is final." The nurse should instruct the client that advance directives can be changed at any time. "This means I have outlined my wishes for medication treatment." The purpose of advance directives is to outline the client's wishes if he becomes unresponsive. "My partner will need to be present if I become unresponsive." MY ANSWER The client's partner does not need to be present if the client comes unresponsive. The nurse should place a copy of the client's advance directives on the medical record so the client's wishes are clear. "My provider will make my health care decisions if I am unable." The client's provider does not make the client's health care decisions if he becomes unable. The provider will follow the client's wishes as outlined in the advance directives.
"I should use mechanical restraints when a client who is manic starts pacing." "I should document every hour when a client is in mechanical restraints." "I should request the provider to examine the client within 1 hour of applying mechanical restraints." "I should check the client every 30 minutes while in mechanical restraints."
"I should use mechanical restraints when a client who is manic starts pacing." A nurse should not restrain a client who is manic and pacing, as this behavior is an expected finding and assists the client in managing excess motor energy. "I should document every hour when a client is in mechanical restraints." A nurse should assess and document every 15 min for range of motion, circulation, and psychological status when a client is in mechanical restraints. ***"I should request the provider to examine the client within 1 hour of applying mechanical restraints." The provider should evaluate the client within 1 hr of initiation of the mechanical restraint. "I should check the client every 30 minutes while in mechanical restraints." A nurse should constantly observe a client who is in mechanical restraints.
"You should set aside time to plan your day at the beginning of each shift." "You should not take a break until all of your tasks are completed." "You should leave your hardest task for the end of the shift." "You should save your charting for the end of the shift."
"You should set aside time to plan your day at the beginning of each shift." MY ANSWER Making time to prioritize and plan at the beginning of each shift is an appropriate time-management strategy because it improves organization and efficiency. "You should not take a break until all of your tasks are completed." The newly hired nurse should take scheduled breaks to prevent mental and physical fatigue, which could impair the nurse's ability to complete tasks by the end of the shift. "You should leave your hardest task for the end of the shift." The nurse should schedule tasks in order of their importance while taking into consideration that the first 2 to 3 hr of the workday are typically the most productive. "You should save your charting for the end of the shift."
Remind the staff members that this is a breach of confidentiality. Discuss the issue with the nurse manager. Request that an administrative restriction be placed on the client's record access. Prepare a memo for the facility ethics committee.
***Remind the staff members that this is a breach of confidentiality. When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality. Discuss the issue with the nurse manager. Discussing the issue with the nurse manager is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Request that an administrative restriction be placed on the client's record access. Requesting that an administrative restriction be placed on the client's record access is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Prepare a memo for the facility ethics committee. Preparing a memo for the facility ethics committee is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority.
Determine the effectiveness of planned interventions. Implement strategies to decrease the incidence of UTIs. Develop a plan that outlines the process for data collection. Establish best practice guidelines for reducing the incidence of UTIs.
Determine the effectiveness of planned interventions. The nurse should determine if the planned interventions are effective to determine whether different interventions are needed; however, evidence-based practice indicates that the nurse should take a different action first. Implement strategies to decrease the incidence of UTIs. The nurse should implement strategies to decrease the incidence of UTIs to improve care quality; however, evidence-based practice indicates that the nurse should take a different action first. Develop a plan that outlines the process for data collection. The nurse should develop a plan for data collection to promote consistent data collection and complete results; however, evidence-based practice indicates that the nurse should take a different action first. Establish best practice guidelines for reducing the incidence of UTIs. MY ANSWER Evidence-based practice indicates the nurse should first establish best practice guidelines for reducing the incidence of UTIs in order to have a standard to measure performance.
Documents client tasks at the end of the shift Gathers supplies as needed while completing an activity Groups tasks that are in the same location Skips breaks throughout the day to complete work on time
Documents client tasks at the end of the shift The newly licensed nurse should document client tasks as she completes them throughout the entire shift. Documenting at the end of the shift can lead to inaccuracy of the documentation and possible error. Gathers supplies as needed while completing an activity The newly licensed nurse should think about the steps of an activity ahead of time and gather all the needed supplies before starting the task. This action promotes effective time-management skills. Groups tasks that are in the same location MY ANSWER The newly licensed nurse should group tasks that are in the same location to effectively use her time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills. Skips breaks throughout the day to complete work on time The newly licensed nurse should not skip breaks throughout the shift to complete her work. It is important for the nurse to take breaks as well as eat lunch. This allows the nurse to refresh her mind physically and mentally to prepare for the rest of the shift.
Meta-analysis Experimental study Phenomenology Secondary analysis
Meta-analysis Meta-analysis is a quantitative research method that provides a statistical analysis of multiple studies conducted on the same topic. Experimental study Experimental study is a quantitative research method that uses control and treatment groups to test at least one independent variable. Phenomenology MY ANSWER Phenomenology is a qualitative research method that provides additional understanding of participants' experiences with emotional variances, such as grief and hope. Secondary analysis Secondary analysis is a quantitative research method that uses previously collected data to answer newly formed hypotheses.
Post a memo in the lounge making the monthly meetings mandatory. Appoint a task force to promote attendance at the meetings. Explore the reasons that staff are not attending the meetings. Change the monthly meetings to quarterly meetings.
Post a memo in the lounge making the monthly meetings mandatory. The nurse should post a memo in the lounge to remind the staff about the meetings; however, evidence-based practice indicates that the nurse should take a different action first. Appoint a task force to promote attendance at the meetings. Appointing a task force to promote attendance at meetings is important to remind the staff about the meetings; however, evidence-based practice indicates that the nurse should take a different action first. Explore the reasons that staff are not attending the meetings. MY ANSWER According to evidence-based practice the nurse should first identify the reasons that staff are not attending the meetings. Change the monthly meetings to quarterly meetings. Changing the monthly meetings to quarterly might improve attendance; however, evidence-based practice indicates that the nurse should take a different action first.
Provide information about alternate birth control methods. Ask the client if she has her partner's approval. Emphasize the benefits of having the procedure. Discuss the client's feelings about the procedure.
Provide information about alternate birth control methods. This is a nontherapeutic response that is dismissive of the client's concerns. Ask the client if she has her partner's approval. This is a nontherapeutic response that is dismissive of the client's concerns. Emphasize the benefits of having the procedure. This is a nontherapeutic response that is giving the nurse's approval. Discuss the client's feelings about the procedure. MY ANSWER The nurse should encourage the client to discuss her feelings about the procedure in order to explore her emotions and what concerns she might have.
Report the findings to the hospital ethics committee. Alert central supply. Fill out an incident report. Notify the quality improvement team.
Report the findings to the hospital ethics committee. The nurse manager should not report a trend in VAP to the ethics committee. The hospital ethics committee assists with difficult or ambiguous value issues related to client care. Alert central supply. It is possible that a problem with the ventilator tubing or accessories is causing the trend in VAP. Other hospital personnel will investigate the cause and notify central supply at a later time, if needed. Fill out an incident report. The nurse should complete an incident report to describe events that involve a single, unusual client or visitor situation. Notify the quality improvement team. MY ANSWER The nurse should report any unusual occurrences or trends such as VAP within the unit to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes.
Subjective comments about the client Routine morning care the nurse provided The client's insurance provider The time of the client's last pain medication
Subjective comments about the client Making subjective comments about a client is unprofessional behavior and does not contribute to the client's care. Routine morning care the nurse provided The nurse should only include recent changes related to the client's condition. The client's insurance provider The name of the client's insurance provider does not pertain to the continuity of care between shifts. The time of the client's last pain medication MY ANSWER The nurse should include the time of the client's last dose of pain medication to ensure continuity of care and management of the client's pain.
Take extra wheelchairs to the emergency department. Send PACU assistive personnel to assist with triage. Identify stable clients for transfer to a surgical unit. Report to the command center for further instructions.
Take extra wheelchairs to the emergency department. The charge nurse should delegate an assistive personnel to take extra wheelchairs to the emergency department, if needed. Send PACU assistive personnel to assist with triage. It is not within an assistive personnel's scope of practice to perform triage. Identify stable clients for transfer to a surgical unit. MY ANSWER It is within the charge nurse's range of function to identify stable clients for discharge to a surgical unit. This action will facilitate the facility's ability to do the most good for the greatest number of clients. Report to the command center for further instructions.
