PN Management Online 2023 A
A nurse is preparing to care for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse plan to take first?
Take the client's vital signs.
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance?
The client has a circular area of non-blanchable discoloration on their left heel.
A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse plan to take? (Select all that apply.)
Select an interpreter who is the same gender as the client is correct Ensure interpreters provided by the facility have knowledge of medical terminology is correct Choose an interpreter who speaks the same language as the client is correct
A nurse is supervising an assistive personnel (AP) who is faxing a client's morning laboratory results to a provider's office. Which of the following actions by the AP requires intervention by the nurse?
Sends laboratory results from the past week
A nurse at a rehabilitation facility is participating in an interprofessional care conference for a client who is 1 week postoperative following an above-the-knee amputation. Which of the following findings is the priority for the nurse to report at the conference?
The client's incision site has purulent drainage.
A nurse is delegating tasks to assistive personnel (AP). Which of the following statements by the nurse includes the five rights of delegation?
"Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath."
A charge nurse in a long-term care facility is reviewing message boards in various client rooms. Which of the following information should the charge nurse request one of the nurses remove from a client's board?
"Hospice nurse visit at 1600"
A nurse is reinforcing teaching about home safety with an older adult client. Which of the following client statements indicates an understanding of the teaching?
"I should participate in a supervised exercise program."
A nurse is reinforcing teaching about home safety with an older adult client. Which of the following statements by the client indicates an understanding of the teaching?
"I will paint the edge of each of my entry steps a different color."
A nurse in a provider's office is reinforcing discharge teaching with an adult client who has a new prescription for ear drops for an inner ear infection. Which of the following instructions should the nurse include?
"Lie on your side when preparing to instill the ear drops."
A nurse is discussing the meaning of utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this ethical theory?
"Utilitarianism provides the greatest good for the greatest number of people."
A nurse in a long-term care facility is caring for a client who had a stroke 1 week ago. The client is experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and memory loss. Which of the following referrals is the priority for the nurse to make?
Speech therapy When using the airway, breathing, circulation approach to client care, the priority referral is to the speech therapist. Difficulty swallowing indicates that this client is at risk for aspiration. Therefore, a referral for speech therapy is the priority.
A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations.
A charge nurse in a long-term care facility is monitoring the activities of an assistive personnel (AP). Which of the following actions by the AP indicates that the charge nurse should intervene?
Stands with feet close together while transferring a client from the bed to a chair
A nurse arrives for their shift and is assigned more clients than they feel is safe. The charge nurse states there are no other options due to a shortage in nursing staff. Which of the following actions should the nurse take?
Submit a written complaint to the nursing supervisor.
A nurse is collecting data from a client following abdominal surgery. The nurse should identify that which of the following findings is the priority to report to the provider?
Surgical dressing saturated with bloody drainage
A nurse is assisting with the development of a presentation for newly licensed nurses regarding client confidentiality. Which of the following actions should the nurse include as an example of a breach of client confidentiality?
Assessing client medical records from other units to compare outcomes with currently assigned clients The nurse should only access the medical records of currently assigned clients. Accessing client records from other units is a breach of client confidentiality and can result in disciplinary and legal action.
A nurse is contributing to the plan of care for a client who has acute hypothyroidism. Which of the following interventions should the nurse include in the plan?
Provide the client with a reduced-calorie diet.
A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following members of the interprofessional health care team should the nurse consult to assist the client with glucose management?
Registered dietitian
A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first?
A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent
A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients?
A client who has burns to the trunk and legs
A nurse is assisting with the selection of clients to discharge to make beds available following a tornado in the community. Which of the following clients should the nurse recommend for discharge?
A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago
A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first?
A preschooler who has respiratory syncytial virus and is wheezing When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority client is the preschooler who is wheezing because this client is at risk for a possible airway obstruction.
A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation?
A treatment that was refused by the client
A nurse on a pediatric unit is assisting with the care of a group of clients. Which of the following clients would benefit most from an interprofessional care conference?
An infant who has cystic fibrosis and is continuing to lose weight
A nurse is completing documentation on the computer at the nurses' station when an assistive personnel (AP) requests to use the computer to enter morning vital signs. Which of the following actions should the nurse take?
Ask the AP to find another computer.
A nurse is contributing to the plan of care for a client who is newly admitted to a rehabilitation facility. Which of the following actions should the nurse take first?
Ask the client to identify their goals for recovery
A nurse on a facility's performance improvement team is assisting to develop practice guidelines for performing bladder scans. Which of the following actions should the nurse take prior to developing a policy and procedure for this task?
Review evidence-based practice data related to bladder scanner use.
A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 2200. Which of the following recommendations should the committee make?
Check on clients hourly -Evidence-based practice has shown that performing hourly rounds to provide assistance with toileting, pain, or client positioning is effective in reducing falls.
A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. The client reports falling while trying to go to the restroom. Which of the following actions should the nurse take first?
Check the client for injuries. When using the nursing process, the nurse should identify that the priority action is to collect data from the client. Therefore, the first action the nurse should take is to check the client for injuries.
A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug in the client's electrical outlet. Which of the following actions should the nurse take first?
Evacuate the client. The greatest risk during a fire or a threat of fire is injury to the client or others. Therefore, the first action the nurse should take is to evacuate the client from the room. This action is the first step of the Rescue, Alarm, Confine, and Extinguish (RACE) protocol.
A nurse is assisting with the care of a client who was admitted with deep-vein thrombosis. The client has decided to leave against medical advice. Which of the following actions should the nurse take?
Explain to the client the risk involved in leaving the facility
A nurse is reinforcing teaching with a newly licensed nurse about the administration of opioid pain medication. Which of the following instructions should the nurse include?
Have a second nurse witness disposal of the unused portion of the client's medication
A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The client has a portable wound bulb suction device and an indwelling urinary catheter. The nurse should recognize that the client's output is calculated and recorded correctly when the AP performs which of the following actions?
Includes emesis and wound drainage in the total recorded output.
A nurse is caring for an adolescent client who requires a blood transfusion. The client's parents will not consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take?
Inform the charge nurse and recommend that social services be contacted.
A nurse is observing an assistive personnel (AP) provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks?
Making a surgical bed for a client returning from surgery
A charge nurse is planning a discussion concerning scope of practice with a group of newly licensed practical nurses (LPNs). Which of the following tasks should the charge nurse identify as within the scope of practice for an LPN? (Select all that apply.)
Participate in health promotion counseling for a client is correct. Evaluate a client's response to nursing interventions is correct Assist in the development of unit policies affecting client care is correct
A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurse should identify that which of the following procedures requires an additional written informed consent?
Performing an amniocentesis The nurse should ensure that the client has provided additional written informed consent prior to an invasive procedure, such as an amniocentesis.
A nurse is monitoring a client who is receiving IV fluids via an infusion pump and notes the pump is malfunctioning. Which of the following actions should the nurse take?
Place a tag on the IV pump.
A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for the client at home?
Portable suction
A nurse is preparing to delegate assignments after receiving change-of-shift report. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
Provide postmortem care
A nurse is participating on a committee that is revising the facility's policies and procedures for infection control. Which of the following instructions should the nurse recommend including in the facility's infection control manual?
Use a 1:10 bleach solution to clean blood spills.
A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides?
Use sentences that have a maximum of six words.
Which of the following findings in the client's electronic health record indicate that a referral for a speech path Nurses' Notes 0930: Assistive personel (AP) noted that client was pocketing food in their mouth at breakfast. Provider requests that nurse monitor client during next feeding. ologist is needed?
When analyzing cues the nurse should identify pocketing food, cough, uncoordinated speech, and a change in voice quality are warning signs of dysphagia; therefore, a referral for a speech pathologist is indicated to perform a swallow study and to determine the assistance the client needs.
Which of the following findings require notification of the char Nurses' Notes Day 1, 0830: Client has stage 3 pressure injury on heel of foot. Full-thickness loss with exposure of adipose tissue. Tissue is beefy red with granulation and rolled edges. Slough and eschar present. Wound is 2.5 cm (1 in) by 2.5 cm (1 in) and 4 cm (1.6 in) deep. Peripheral pulses +1 bilaterally. Client reports pain is a 2 on a pain scale of 0 to 10. ge nurse and requires a change in assignment?
When assisting with the plan of care, the nurse should identify that an increase in heart rate, temperature, and WBC count along with a decrease in blood pressure and prealbumin level can indicate an increased risk for sepsis. The nurse should notify the charge nurse of these findings.
A nurse is assisting with the care of a client on a medical-surgi Nurses' Notes 0900: Client newly admitted to the unit reports of increased confusion, urinary urgency, and episodes of dizziness. Client has a history of dementia and falls at home. cal unit. Which of the following statements by the assistive personnel indicates an understanding of the instructions? Select 4 statements that indicate understanding.
When evaluating outcomes, the nurse should identify that the assistive personnel's (AP) statements of activating the bed alarm, providing frequent toileting, ensuring the client's bed is in the lowest position, and placing a bedside commode next to the client's bed indicates an understanding of the instruction. The client is confused, has a history of dementia, and is experiencing urinary frequency and dizziness. The AP should be instructed to offer frequent toileting to the client to minimize the client's need to get out of bed without assistance. Activating a bed alarm will alert personnel of the client's attempt to get out of bed, allowing personnel to assist the client and minimize the risk of falling. Ensuring the client's bed in in the lowest position will minimize injury in the event of a fall. Placing a bedside commode next to the client's bed will minimize the client needing to ambulate to the bathroom.
A nurse on a maternal newborn unit is reviewing the below information regarding the clients on the unit prior to delegating client care needs. For each "Client and Time" click to specific if it is appropriate or inappropriate for delegation of their tasks to an AP.
When evaluating outcomes, the nurse should recognize that it is crucial to positive outcomes for the nurse to appropriately delegate tasks to the AP. The AP can assist with diaper changes and perineal care. They can also obtain vital signs, measurements, and an axillary temperature. These tasks are commonly within the range of function for an assistive personnel. The following tasks are not appropriate to delegate to the AP and include, providing information about use of bulb syringe, breastfeeding, and safe sleep practices. These tasks require client education and cannot be performed by the AP. Also, the AP cannot assist a client with perineal care who is reporting passing several clots. Finally, an AP cannot witness a consent for a circumcision. These are all tasks that should be performed by the PN or RN and is dependent on the scope of practice.
The nurse is assisting in evaluating and updating a client's plan of care. Which of the following findings indi Nurses' Notes Day 1, 1530: Client presents to the emergency department with reports of a cough, sore throat, chills, fever, and shortness of breath which began 2 days ago. Client reports their sputum is thick and yellow in color. Upon auscultation, lungs sounds cate that the client's condition is worsening?
When evaluating the client's plan of care the nurse should identify blood-tinged sputum, an increase in temperature, heart rate, respiratory rate along with a decrease in oxygen saturation indicates the client's pneumonia is worsening. Therefore, the nurse should contact the provider for further instructions.
A newly hired nurse observes that the unit staff is in constant conflict with the nurse manager. The nurse notes that the nurse manager has decided that their own plans are best, and the unit staff is no longer trying to resolve conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches?
Win-Yield The nurse should identify that the nurse manager is using the win-yield approach to conflict management. With this approach, the manager is always right and the staff is no longer trying to resolve conflict. This can create an oppressive working environment on the unit.
A nurse is participating in a peer evaluation system based on overall performance of its nursing staff. Which of the following strategies ensures that the peer evaluation process is impartial and fair?
uses the same objective measurement tool for all nurses An objective measurement tool based on established standards provides consistent criteria for evaluation and decreases the amount of subjectivity.
