RN lesson 1 Management of Care

ref# 1716 The nurse receives an illegible hand-written medication order from the primary health care provider (HCP). Which is the most appropriate statement made by the nurse to the HCP? "I need you to clarify what you have written so I am sure I am reading it correctly." "I'm sorry, but I cannot administer this medication with this order." "I have spent a lot of time trying to read this order and I can't figure it out." "Please write your orders more legibly in the future."

"I need you to clarify what you have written so I am sure I am reading it correctly."

ref#4512 The nurse is giving change-of-shift/hand-off report to the nurse from the next shift. Which statements are appropriate to include in the report? Select all that apply. "The client has been irritable and rude to staff members." "The client's heart rate has been ranging from 60 to 80 bpm." "The client has a history of hyperlipidemia." "The client has declined a cardiac catheterization procedure." "The client was admitted for a myocardial infarction."

"The client's heart rate has been ranging from 60 to 80 bpm." "The client has a history of hyperlipidemia." "The client has declined a cardiac catheterization procedure." "The client was admitted for a myocardial infarction."

ref#5470 The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? Select all that apply. "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" "Have you thought about your options for a heart transplant?" "Someone in your family needs to learn how to do cardiopulmonary resuscitation (CPR)."

"What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" "Have you thought about what you want done as your disease progresses?"

ref#4590 The nurse is preparing to call the health care provider (HCP) about a change in a client's condition. Following the Situation-Background-Assessment-Recommendation (SBAR) model, in which order should the nurse provide the following information? List the correct order by dragging and dropping the options below. -1"I am calling because this client is experiencing hypotension. The blood pressure has dropped from 110/64 to 82/48." -2"The client was admitted last night for dehydration and low urine output. The client has no history of cardiac or renal problems." -3"The client is awake and alert. Urine output was 120 mL total for the last eight hours. The current heart rate is 112." -4"I would like to recommend an IV fluid bolus."

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ref #4465 The nurse in the emergency department is admitting a client for pneumonia and sepsis. The health care provider (HCP) has given the nurse orders. Prioritize the order of implementation from highest (1) to lowest (5) priority. -1Apply oxygen at 2 L/min via nasal cannula. -2Start an IV infusion of 0.9% NaCl at 100 mL/hr. -3Obtain a set of blood cultures. -4Give ceftriaxone 1 gram every 12 hours IVPB. -5Teach the patient how to use incentive spirometry.

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ref#2310 The nurse on an inpatient hospital unit is making nursing assignments for the upcoming shift. Which client is not appropriate to assign to the licensed practical nurse (LPN)? A 45-year-old client with orders to have a nasogastric tube placed. An 82-year-old client who needs medications administered through a gastrointestinal tube. A 52-year-old client with an order to remove an indwelling urinary catheter. A 24-year-old client who needs to be taught how to self-administer insulin injections.

A 24-year-old client who needs to be taught how to self-administer insulin injections.

ref#4548 The nurse on a post-surgical orthopedic unit receives nursing report on a group of adult clients. Which client should the nurse see first? A client who has not had a bowel movement since before surgery. A client whose reported pain level is 8 out of 10. A client who has a respiratory rate of 8 breaths/min. A client who has some bloody drainage on the surgical dressing.

A client who has a respiratory rate of 8 breaths/min.

ref#4553 The nurse receives their client care assignment for the upcoming shift. The nurse has been assigned a client with a nephrostomy tube. The nurse has never cared for a client with a nephrostomy tube before. Which is the most appropriate action by the nurse? Conduct a literature review about proper nephrostomy tube care. Plan to check-in with the charge nurse and the client often during the upcoming shift. Ask the charge nurse to provide an in-service about nephrostomy tube care. Ask the charge nurse to change the assignment to a different nurse.

Ask the charge nurse to change the assignment to a different nurse.

ref#2184 The nurse in a preoperative surgery unit is reviewing the chart of a client who is scheduled to have a laparoscopic cholecystectomy today. The nurse notices the client has not signed the surgical consent. Which action would be most appropriate for the nurse to take? Initiate the Universal Protocol procedure and begin the surgical "time-out" process. Ask the client to sign the consent form and then the nurse can sign as the witness. Contact the surgeon and tell them that the client has not signed the consent form yet. Ask the client first if they understand the surgical procedure listed on the consent form.

Ask the client first if they understand the surgical procedure listed on the consent form.

ref#2495 The nurse is caring for a client who had an appendectomy two hours ago. Which is the most reliable approach for the nurse to assess the client's postoperative pain? Observe the client for behaviors such as guarding, bracing or splinting of the surgical site. Monitor for non-verbal signs of pain, such as grimacing and crying. Check for changes in the client's vital signs, such as tachycardia. Ask the client to rate their pain using a pain rating scale.

Ask the client to rate their pain using a pain rating scale.

ref#2438 The nurse is planning a teaching session with a client about a new diagnosis of congestive heart failure. The nurse and client do not speak the same language. The nurse arranges for an interpreter to be present for the teaching session. Which nursing concept is this an example of? Confidentiality Quality improvement Client advocacy Informed consent

Client advocacy

ref#2236 The nurse in a long-term care facility is planning care for a client who has a colostomy in place. Which task is appropriate to delegate to the unlicensed assistive person (UAP)? Measure the size, shape and color of the stoma. Teach the client and family about proper colostomy care. Empty the colostomy bag contents and report the output amount. Change the colostomy wafer and bag apparatus.

Empty the colostomy bag contents and report the output amount.

ref#5018 The nurse is caring for a client who had a total hip arthroplasty two days ago. The client is requiring two staff members to assist with transferring from the bed to the chair. The client is scheduled for discharge to home the next day. Which action is a nursing priority? Inform the case manager of the concerns about the client's mobility. Contact the client's family to discuss the client's mobility problems. Instruct physical therapy to increase the frequency of treatments. Reinforce teaching about hip precautions and proper walker use.

Inform the case manager of the concerns about the client's mobility.

ref#4604 The charge nurse in the emergency department receives a radio call from Emergency Medical Services (EMS) stating that there has been a large structure fire with multiple victims. Which action should the charge nurse take first, before the victims start to arrive? Call for a medical evacuation helicopter to be on standby. Activate the disaster plan. Notify the nursing supervisor and request additional staff. Prepare the trauma room and lay out supplies.

Notify the nursing supervisor and request additional staff.

ref#4600 The nurse is caring for a client who is admitted for a gastrointestinal bleed. The health care provider (HCP) gives an order for subcutaneous enoxaparin for venous thromboembolism (VTE) prophylaxis. Which action should the nurse take? Ask another staff nurse if they agree with the order. Request a consult with the in-house pharmacist. Follow the order and administer the medication. Page the health care provider and clarify the order.

Page the health care provider and clarify the order.

ref#2371 The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female client who is experiencing urinary retention. After the nurse inserts the catheter, no urine outflow appears. Which action should the charge nurse take? Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone. Leave the catheter in place and check for urine output in 15 minutes. Remove and re-lubricate the catheter and assist the nurse with re-insertion. Remove the catheter and have the nurse get a new catheter and insertion kit.

Remove the catheter and have the nurse get a new catheter and insertion kit.

ref#1874 Two nurses on an inpatient hospital unit are completing a change-of-shift report in a client's room. The nurses get into a verbal argument in front of the client. The nurse manager is notified of the incident the next day. Which is the best way for the nurse manager to resolve the issue? -Stay neutral and allow the nurses to handle this situation independently. -Notify human resources about the breach of professional conduct. -Walk up to both nurses and say, "You must stop this unacceptable behavior." -Request a private meeting with both nurses and the nurse manager.

Request a private meeting with both nurses and the nurse manager.

ref#4554 The nurse on an inpatient hospital unit notices an unfamiliar person viewing a client's medical record. The person has no visible identification badge. The nurse asks the person who they are, and they state they are from a local assisted living facility. Which action by the nurse is most appropriate? Request to see identification and an explanation for reviewing the client's record. Call the security office to report the person and their actions. Ask the person to fill out and sign the facility's Notice of Privacy Practices form. Allow the person to continue reviewing the client's record.

Request to see identification and an explanation for reviewing the client's record.

ref#1877 At a monthly staff meeting, the nurse manager is discussing quality improvement initiatives on the hospital nursing unit. Which is an example of a quality improvement outcome indicator? The number of clients who receive smoking cessation information. The amount of time it takes for nurses to administer medications. The frequency of postoperative wound infections on the unit. The percentage of clients who have Medicare insurance.

The frequency of postoperative wound infections on the unit.

ref#4569 The public health nurse is working at a screening clinic for sexually transmitted infections. A client has tested positive for human immunodeficiency virus (HIV). Which action should the nurse plan for next? The client will be required to notify all past sexual partners. The positive test result must be reported to the local health department. The client will need extensive teaching about acquired immunodeficiency syndrome (AIDS). The client should be medicated with tenofovir/emtricitabine for pre-exposure prophylaxis.

The positive test result must be reported to the local health department.