Nursing Leadership & Management
A bladder irrigation is prescribed for a client who has an occluded indwelling urinary catheter. Which of the following actions should the nurse take when unsure of how to perform this procedure? A. refuse to perform and notify provider B. refer to the policy and procedure manual C. instill solution slowly and observe for signs of pain D. delay irrigation and inform the next nurse assigned
B (Policies and procedures are maintained by each facility to establish the standard of practice for employees. These documents should be followed according to institutional guidelines.)
A nurse assigns care for a client who has DM to the LPN and UAP. Which of the following tasks should be delegated to the LPN? A. measure UO B. apply anti-embolic stockings C. assist with bedside commode D. obtain capillary blood glucose
D (Obtaining capilary blood glucose is within the scope of practice for the LPN. This is the most appropriate task to assign.)
A nurse should prepare to notify public health officials about which of the following client infections? (Select all that apply.) A. gonorrhea B. hep C C. clostridium difficile D. chlamydia trachomatis E. meningococcal disease
A, B, D, E (The CDC provides an annual list of infections for surveillance. Information is used to monitor, control, and prevent the occurrence and spread of state-reportable and nationally notifiable infectious and noninfectious diseases and conditions.)
A nurse receives a client's medication prescription over the telephone from the provider. Which of the following actions should the nurse take? A. repeat the prescription back to the provider B. ensure the provider signs the prescription immediately C. instruct the provider to submit the prescription electronically D. request another nurse to witness the provider's prescription
A. (To prevent an error, the nurse should repeat the prescription back to the provider, including the med name, dosage, time, and route. The nurse should review all prescriptions and identify potential contraindications requiring clarification.)
During a home health assessment, the nurse witnesses a school-age child fall from a second story window. Which of the following is the priority action? A. tell the child not to move B. provide support to the parents C. apply pressure to bleeding D. place the child on a rigid board
A. (The nurse should recognize a spinal cord injury may exist. In any circumstance when a spinal injury is suspected or a possibility, the child should be calmed, reassured, and instructed not to move. No one should be allowed to move the child until the entire spine is stabilized.)
A nurse receives an end-of-shift report. Which of the following client assessment findings should the nurse address first? A. BP of 105/70 mmHg in a client who is dehydrated B. new onset of confusion in a client who has a left femur fracture C. blood glucose of 140 mg/dL in a client who has DM D. decreased bowel sounds in a client who is 2 d post-op
B. (New onset of confusion is not an expected finding. Confusion can be an indication of hypoxia and requires immediate assessment to prevent additional complications.)
A nurse participates in quality improvement to decrease hospital readmissions of clients who have heart failure. Which of the following actions should the nurse expect to perform? A. discuss staff performance appraisals with team B. compare performance to current practice standard C. reinforce evidence-based practice guidelines to staff D. interview all nurses caring for clients who are readmitted
B. (Quality improvement process is designed to correct discrepancies between developed standards and actual performance. Once a standard is developed, approved, and made available to staff, quality issues can then be identified.)
A client arrives to the ED and reports a HA, neck stiffness, and sensitivity to light. Which of the following is the priority nursing action? A. notify recent contacts B. administer acetamiophen C. implement droplet precautions D. decrease environmental stimuli
C (The client is reporting s/s of meningitis and will require droplet transmission precautions until a definitive diagnosis is made. Bacterial meningitis is highly contagious and potentially life-threatening.)
A nurse completes a home health assessment on an older adult who has a broken arm and burn marks to the chest. The caregiver states injuries were sustained from a fall. Which of the following actions is needed at this time? A. administer ibuprofen PRN B. implement sz precautions C. contact adult protective services D. provide teaching to promote safety
C. (The client's presentation does not match the caregiver's story. The patient's injuries are suspicious signs of abuse. Nurses should report any suspicion of abuse, following facility policy, to the appropriate state agency.)
A client who has stage IV pancreatic cancer decides to discontinue all treatment. Which of the following actions should the nurse take? A. offer alternative meds B. encourage the client to reconsider C. ask the client to discuss the decision D. request a mental health consultation
C. (The nurse should respect the client's decision to discontinue treatment. The client has the right to decide what course of action is most appropriate to meet their goals. This response will allow the nurse to gather additional information to serve as a better advocate for the client.)
A client has a new diagnosis of stage IV lung cancer. When the partner requests the diagnosis be withheld from the client, which of the following actions should the nurse take? A. withhold the diagnosis from the client B. contact the institution's ethics committee C. document the request in the medical record D. request additional information from the partner
D. (The nurse should gather all information relevant to the situation to determine the next course of action.)
A nurse reviews the plan of care for a client who has myasthenia gravis. Which of the following interventions requires a revision? A. monitor for sudden increases in weakness B. perform pulmonary percussion and postural drainage C. refer to speech and occupational therapy for evaluation D. assist with daily activities prior to medication administration
D. (This nursing intervention should be revised. To maximize independence, daily activities should be scheduled to follow medication administration, not prior to administering medications. The nurse should also plan rest periods for the client to prevent increased fatigue.)
A charge nurse reviews abbreviations used in client documentation. Which of the following is an approved entry? A. Enoxaparin 30 mg SC BID B. Zolpidem 5.0 mg PO qhs C. Digoxin .125 mg IV q24h D. Furosemide 60 mg PO daily
D. (Following the rule of do not use a trailing zero for doses expressed in a whole number, 60 is correct. "PO" is an abbreviation that may be used and is not included in the joint commission Do Not Use list. "Daily" is correct, following the rule to spell out the word daily.)
A unit manager observes several nurses working throughout the day. Which of the following actions represents a breach in client confidentiality? A. shredding a client's printed lab results B. giving report to the oncoming nurse at the bedside C. logging off the computer prior to leaving a workstation area D. posting positive information about a client on a social media website
D. (Posting client information on a social media website is a breach of confidentiality. Nurses must not disclose client information to unauthorized individuals.)
A client who is newly admitted requests information about advance directives. The nurse should include which of the following statements in the discussion? A. "An advance directive may not be changed." B. "Advance directives are only discussed with terminally ill clients." C. "You will need to designate a relative to act as your health care proxy." D. "I will give you a pamphlet with written information about advance directives."
D. (The patient self-determination act requires that all patients admitted to a healthcare facility be asked if they have an advance directive. Clients who do not must be given written information.)
