RN Leadership 2023 A Rational

A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives?

"A family member of a client can have the living will overturned in some cases." Family members have the right to question the mental capacity of the client at the time a living will was completed; evidence that the client was incompetent could result in the living will being revoked.

A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions?

"After I finish with the printout of my assignment, I'll put it in the shredder receptacle." The nurse should shred all computer printouts and worksheets that contain clients' protected health information to maintain client confidentiality

A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Clients on a mental health unit can refuse their medication." Regardless of the type of health care facility or admission status, clients maintain the right to refuse medications.

A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing about the failure of the AP to restock unit supplies. The AP leaves the room. Which of the following statements should the nurse manager make to the newly licensed nurse?

"I would like for you to approach the AP to resolve the problem." Encouraging face-to-face communication to resolve a conflict is an appropriate action by the nurse manager.

A nurse is teaching a newly licensed nurse about using electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"My access to client electronic records might be tracked by my nurse manager." The nurse should be aware that the nurse manager might track access to client records to ensure client confidentiality.

A charge nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates the teaching was effective?

"There must be documentation in the medical record about whether a client has advance directives." The client's medical record should indicate whether a client has advance directives, in order to provide medical care and make decisions based on the client's specified wishes.

A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

"Your case manager will coordinate the resources you will need."

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? Select all that apply.

1.The right to be treated with respect and dignity. 2.the right to refuse their medications, 3. the right to leave regardless of provider recommendations 4. the right to be fully informed of their health conditions

A nurse is caring for a client who speaks only Spanish and is to undergo hip arthroplasty the next day. The client's child speaks English and is in the room with them. Which of the following actions should the nurse take? Select all that apply.

1.Use a Spanish/English medical dictionary to assist with communication, 2.enlist the help of the bilingual assistive personnel (AP) assigned to the client, 3.request that the hospital's Spanish interpreter help the nurse provide education Ask the child to help interpret for their parent is incorrect. A family member is not an appropriate interpreter because they may not relay the information accurately, may feel uncomfortable discussing personal issues, and may try to influence the client to make a particular decision. Use a Spanish/English medical dictionary to assist with communication is correct. The nurse should use a Spanish-English medical dictionary to assist in communicating with the client. Enlist the help of the bilingual assistive personnel (AP) assigned to the client is correct. The nurse should enlist the assistance of the AP assigned to the client if the AP also speaks Spanish. Speak loudly when talking to the client is incorrect. The nurse should speak slowly and clearly. The client can interpret a loud voice as disrespectful or angry. Request that the hospital's Spanish interpreter help the nurse provide the education is correct. Having the interpreter assist with providing client education facilitates the client's understanding.

A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?

A client admitted for a fractured hip who has developed slurred speech A client who is admitted for a fractured hip and has developed slurred speech is unstable because this can indicate a cerebrovascular accident; therefore, the nurse should assess this client first.

A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of causalities. Which of the following clients should the nurse recommend the provider evaluate first?

A client who has a sucking chest wound

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who has peripheral vascular disease and has an absent pulse in the right foot 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 home health nurse is planning daily visits and receives laboratory results for 4 adult clients. Which of the following clients should the home health nurse plan to visit first, based on their laboratory findings?

A client who is 3 days postoperative and has a platelets 100,000/mm3 (150,000 to 400,000/mm3) A client who has a decreased platelet count is at increased risk for bleeding which is a concerns for the nurse. Therefore, according to the airway, breathing, and circulation framework, the nurse should see this client first.

A nurse has just received a report on four clients on a medical-surgical unit. Which of the following clients should the nurse plan to assess first?

A client who is postoperative following a total knee arthroplasty and has a capillary refill of 4 seconds When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority is a client who has a capillary refill of 4 seconds following a total knee arthroplasty. Capillary refill should be 3 seconds or less.

A nurse manager is reviewing recent actions by staff to determine adherence with HIPPA guidelines. Which of the following actions by a nurse should the manager identify as adhering to HIPPA guidelines?

A nurse shares a client's test results with an AP on the same nursing team The nurse should only give information to individuals who have a right to know the information, including members of the same nursing team who are providing care. Therefore, this action adheres to HIPAA guidelines.

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

Advise the client to install grab bars in the bathroom at home The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls.

A nurse manager is presenting an in-service about preventing readmission of clients due to complications following joint arthroplasty. Which of the following leadership tasks is the nurse performing?

Advocacy The nurse acts as an advocate by promoting and protecting safety for staff and clients by providing information that allows staff to act autonomously.

A charge nurse is supervising a team of licensed practical nurses (LPNs) and assistive personnel (AP). The charge nurse should intervene in which of the following situations?

An LPN develops the nursing plan of care for a client who has pneumonia Developing a nursing plan of care is not within the LPN's scope of practice.

A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed 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.

A charge nurse is observing a newly licensed nurse care for a client who has a prescription for application of an aquathermia pad to the right lower leg. Which of the following actions should indicate to the charge nurse that the nurse understands how to use the device? Select all that apply.

Asks the client to report if the aquathermia pad gets too warm, ensures that the client's call light is in reach Asks the client to report if the aquathermia pad gets too warm is correct. The nurse should instruct the client to report if the aquathermia pad gets too warm because it can cause client injury. Checks the client's leg 30 min after applying the aquathermia pad is incorrect. The nurse should check the client's leg 15 to 20 min after applying the aquathermia pad to ensure there is no evidence of complications. Shows the client how to adjust the temperature is incorrect. The nurse should not show the client how to adjust the temperature. Temperature adjustments can result in pain and impaired circulation. Ensures 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. Decreases the temperature by 2.8° C (5° F) if the client's skin becomes discolored is incorrect. The nurse should monitor the client's skin for increased discoloration and should discontinue the aquathermia pad if it is noted. The nurse should report the finding to the provider.

A charge nurse is delegating tasks on nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the charge nurse take?

Assign the procedure to a licensed practical nurse (LPN) This task is within the scope of practice of an LPN. The charge nurse should delegate this task to the LPN.

A nurse manager is assessing incident reports for the unit. Which of the following client's medical records indicate professional negligence? Select 2 clients that the nurse manager should recognize have charts that indicate professional negligence.

Client 4, Client 5 When recognizing cues, the nurse should identify client 4 and client 5 have medical records that indicate instances of professional negligence. Professional negligence occurs when an individual with professional training fails to practice at the level expected of their profession and harm is caused to a client. For professional negligence to occur there must be a correlation between the nurse's actions and the harm that came to the client. In client 4's medical record, the nurse failed to administer the client's prescribed antiseizure medication within the indicated time frame and the client experienced a seizure. In client scenario 5's medical record, the nurse administered the client's medications outside the parameters indicated on the prescription and the client experienced syncope and sustained an injury. The nurse should identify these two client scenarios as instances of professional negligence.

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

Compare data from clients' records regarding skin integrity with established criteria

An RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of the following activities must be performed by the RN?

Completing the client's initial admission assessment Completing the client's initial admission assessment is within the RN's scope of practice.

A charge nurse has been asked to determine staff adherence to establish standards for postoperative vital sign measurement. Which of the following actions should the nurse take to collect information?

Conduct a retrospective chart audit of all surgical clients for the past 6 months A retrospective chart audit is an effective method of collecting objective performance data from formal records that can be used for outcome measurement.

A nurse case manager is planning a teaching session on the use of critical pathways with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching?

Critical pathways prevent unnecessary expense Nurses use critical pathways (also called clinical pathways) to implement evidence-based strategies and promote cost-effective care for clients who have a specific, common diagnosis.

A nurse manager is reviewing client care needs. Which of the following actions should the nurse take when making client care assignments? Select all that apply.

Delegate provider prescription received for client 1 to a registered nurse, delegate provider prescription received for client 3 to a practical nurse, delegate provider prescription received for client 4 to an assistive personnel When taking actions the nurse manager should identify safe parameters for delegating client care activities. Client 1 received a prescription to initiate an intravenous insulin drip, administration of this medication is within the scope of practice of a registered nurse. Client 3 received a prescription for an oral antibiotic, administration of this medication is within the scope of practice of a licensed professional nurse. Client 4 received a prescription for turning and position, tasks such as positioning, ambulation, and personal hygiene can be delegated to an assistive personnel for stable clients.

A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Determine a client's intake and output. The nurse can delegate determining a client's intake and output to an AP, as this does not require the use of the nursing process and is within the range of function of an AP.

A nurse is observing an assistive personnel (AP) who is caring for a group of clients. Which of the following actions by the AP demonstrates effective use of time management skills in providing client care?

Grouping activities for several clients in the same location

A grandparent brings their 15-year-old grandchild to the emergency department reporting that they have severe abdominal pain and are scheduled for an immediate appendectomy. The nurse confirms that the client's guardians are unavailable. Which of the following actions is appropriate?

Have the grandparent sign the consent form The nurse should assist in obtaining informed consent from the client's grandparent in an emergency situation when parents are not available.

A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?

Home health A home health agency can provide nurses who will visit the home and help the guardian learn necessary skills, as well as assess the progress of the infant.

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

Inform the assistive personnel (AP) of the client's weight-bearing status APs can assist clients with ambulation in most cases with appropriate delegation from the nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part of safe care delegation.

A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that they are leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next?

Inform the client about the risks they may encounter by leaving the facility Using the safety/risk reduction framwork, the nurse should recognize that the greatest risk to this client is injury from peritonitis; therefore, the first action the nurse should take is to inform the client about the risks of not receiving treatment.

A charge nurse on a medical unit hears the fire alarm and announcement that a fire is occurring on the unit. Which of the following is the priority action by the charge nurse?

Instruct ambulatory clients to go to a safe area Using the safety and risk reduction priority setting framework and the RACE protocol, rescuing clients from the area is the priority action.

A nurse is working in the emergency department when there is an explosion in a local chemical plant. Multiple victims are expected at the facility. Which of the following should be the nurse's priority intervention upon client arrival?

Isolate the clients and irrigate with water When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to reduce mortality and morbidity.

A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?

LPNs provide care to class II (green tag) clients LPNs can provide care for class III clients, who have nonurgent, minor injuries. Class IV clients are expected to die or have died. This would be an appropriate assignment for assistive personnel, not an RN. Class I clients require immediate attention typically due to airway obstruction or shock. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment. Class II clients require treatment within 30 min to 2 hrs. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment.

A nurse in a long-term care facility is transferring a client to an acute-care facility. Which of the following information should the nurse include when transferring?

List of current medications The nurse should include a list of the client's current medications to maintain continuity of care and provide safe and effective care delivery.

A charge nurse on a maternal newborn unit is receiving change of shift charge nurse report for a group of newborns. Which of the following 3 newborns should the charge nurse identify as requiring priority care? Select 3 newborns the charge nurse should identify as priority.

Newborn 5, Newborn 3, Newborn 1 When prioritizing hypotheses using the urgent vs. non-urgent approach to newborn care, the charge nurse should identify newborn 1, newborn 3, and newborn 5 as requiring priority care based on acuity. Newborn 1 has manifestations of respiratory distress including tachypnea, grunting, nasal flaring, and retractions. The charge nurse should further determine if newborn 1 requires prompt interventions. Newborn 3 presents with manifestations of hypoglycemia including blood glucose below the expected range, hypothermia, and maternal history of gestational diabetes insulin dependent. Newborn 5 is 23 hours of age and has not had a successful feeding. The newborn additionally has not voided or passed their first meconium stool. Newborns are expected to have at least one void during the first 24 hours of life, and one meconium stool with in the first 24 to 48 hours of life. While newborns are sleepier during the first 48 hours after birth, the newborn should be awoken for feedings at least every 3 hours. These finding indicate that further intervention by the nurse is needed.

A newborn is being discharged from the hospital. Which of the following is the best action for the nurse to take to ensure the newborn's safety?

Observe the parent securing the newborn into the infant care seat in the parent's car The greatest risk to the newborn's safety is securing the car seat correctly. Therefore, this is the priority action for the nurse to take.

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?

Perform a chart review to gather data about the clients who developed infections 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.

A nurse is caring for four clients. Which of the following tasks can the nurse assign to an assistive personnel (AP)?

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 an AP's range of function.

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Pick up the first sterile glove by grasping the folded cuff edge 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.

A nurse is caring for a client. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? select all that apply

Place an absorbent pad on the client's bed, report the client's blood pressure to the nurse, apply barrier cream to the client's buttocks, document the client's vital signs

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include?

Raise the footplates of the wheelchair before transferring the client The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury.

A charge nurse on a medical-surgical unit is making assignments for the next shift. A licensed practical nurse (LPN) and an assistive personnel (AP) are members of the team. Which of the following client care assignments should the nurse assign to the LPN?

Reinforcing teaching to a client Reinforcing teaching to a client is within the scope of practice of the LPN. Client education is a responsibility of the nurse; therefore, this task should be assigned to the LPN and not the AP.

When participating in the informed consent process prior to surgery, which of the following actions should the nurse take?

Review previously provided information about the procedure The nurse is responsible for reviewing and reinforcing information the provider gives regarding the procedure and should avoid giving new information.

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse take? Select all that apply.

Role model a positive approach to the changes, encourage staff members who support the changes to discuss the issue with resistant staff 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.

A nurse is caring for a client who is experiencing adverse effects after receiving a new medication. Which of the following communication tools should the nurse use for management of this complication?

SBAR framework The nurse should use the SBAR framework to identify the situation, background, assessment, and recommendation for a specific circumstance. The nurse can focus on the client's immediate circumstances to promote clinical decision making. The nurse should use a critical pathway as a cost-effective strategy to guide care for clients who have a specific medical diagnosis or are undergoing a specific procedure. The nurse should complete an incident report as part of error reporting and quality improvement; however, this action does not relate to management of the client's care. The nurse should use root cause analysis during the quality control process to determine why a standard is not being met.

A charge nurse is assessing a client in a long-term care facility. Which of the following findings indicate that a referral for a speech pathologist is needed? Select all that apply.

Speech coordination findings, cough findings, vocal characteristics during mealtime, observation of food pocketing 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.

A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when the rate was set at 100 mL/hr. After notifying the provider and verifying that the pump was properly programmed, which of the following is the nurse's priority?

Tag the pump for maintenance and acquire a new pump for the client The greatest risk is the potential for injury to a client if a nurse uses the pump again before repair; therefore, the priority for the nurse is to tag the pump for maintenance and acquire a new pump for the client.

A nurse is presenting information on health care law to a group of newly licensed nurses. Which of the following information should the nurse include?

The Patient Self-Determination Act (PSDA) requires a nurse to give clients information about end-of-life options The PSDA was designed to help clients make informed decisions about care; therefore, the nurse should include this information in the presentation.

A nurse is developing a plan of care for a school-age child whose family is without housing. Which of the following findings should the nurse identify as the priority?

The child has red fissures at the corners of the mouth. Using Maslow's hierarchy of needs, the nurse should determine that the priority finding is red fissures at the corners of the child's mouth. This can indicate a vitamin B deficiency, which is a physiological need.

A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?

The client refuses to attend physical therapy sessions The greatest risk to this client is postoperative complications due to immobility, such as atelectasis or pneumonia; therefore, the priority for discussion is the client's refusal to participate in physical therapy.

A nurse manager is planning an educational program about the role of the nurse as a client advocate. Which of the following should the nurse include in the presentation?

The distribution of confidentiality disclosure information to clients Providing information to clients about confidentiality disclosure is an example of a nurse's role as a client advocate.

A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. Which of the following should the nurse manager include in the teaching?

Verify that a provider prescription is in the medical record for clients who have restraints A nurse should verify that there is a provider prescription for a client who has restraints to prevent false imprisonment.

A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?

Wear an N95 respirator mask when in the client's room The nurse should wear an N95 respirator mask when caring for clients who have suspected pulmonary tuberculosis.

There has been a community disaster and stable clients must be discharged from a facility to prepare for the influx of new casualties. A nurse should identify that which of the following clients is safe to discharge?

a client who has multiple sclerosis and reports ataxia This client is safe to discharge because multiple sclerosis is a chronic disorder and ataxia is an expected finding.

A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? select all that apply

ambulating a client who uses a walker, adding thickener to thin liquids on a client's food tray Flushing a client's saline lock is incorrect. This is not within the AP's scope of practice. Ambulating a client who uses a walker is correct. This is within the AP's scope of practice. Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's scope of practice. Teaching a client how to use an incentive spirometer is incorrect. This is not within the AP's scope of practice. Evaluating a client's gag reflex before mealtime is incorrect. This is not within the AP's scope of practice.

A charge nurse is assisting with the care of a client. Which of the following findings should the charge nurse identify that the client is experiencing an adverse reaction and requires notification of provider and updating the client's plan of care? Select 6 findings that indicate that client is having an adverse reaction.

blood pressure, temperature, heart rate, respiratory rate, pain level, report by the client When evaluating outcomes, the nurse should identify hypotension, an increase in temperature, heart rate, and respiratory rate along with reports of abdominal and flank pain as a 6 on a pain scale from 0 to 10 and client report of short of breath and chills can indicate the client is experiencing an acute hemolytic reaction to the blood transfusion. The nurse should stop the transfusion and notify the client's provider immediately. The charge nurse should update the client's plan of care to include interventions to manage the client following an adverse reaction.

A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease?

Chlamydia trachomatis 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.