Saunder's

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

"It represents a primary health prevention focus managed by a single case manager."

The new nurse graduate asks another nurse about the need to obtain professional liability insurance. Which is the most appropriate response by the nurse?

"Nurses need to have their own malpractice insurance."

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?

"I should obtain my own malpractice insurance."

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks the nurse if this document is still effective. Which is the most appropriate nursing response?

"Yes, it is effective but you may want to discuss any changes you desire with your primary health care provider."

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client who is dependent on a ventilator

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As needed medications given that shift

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply.

Date and time entries. 2.Sign and title each entry. 3.Avoid judgmental and evaluative statements. Do not leave blank spaces on documentation forms.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated, and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the primary health care provider.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

Obtaining a telephone consent from a family member and ensuring that the oral consent is witnessed by two persons

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Report the case in which the abuse is suspected.

The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Respiratory status

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?

The presence of dysrhythmias in a client with a myocardial infarction

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

The tertiary level of prevention

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?

To compare a client's medication prescriptions to all of the medications the client is taking at home

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. Which is the most appropriate nursing response to the client?

"A nurse caring for a client cannot serve as a witness to a living will."

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated."

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

"Beneficiaries are limited to those providers that are participating primary health care providers for any required health care services."

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who says that voices sponsored by the FBI are telling him to stab his roommates

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client who was admitted during the night because of a severe exacerbation of asthma

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)?

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)?

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

A few individuals such as the board of directors

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error?

Ask the nurse if he or she intends to report the error.

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

"I have planned to take the day off and will not be able to work on that day."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

"Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs only within the heath care facility and could endanger staff." "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

Which identifies accurate nursing documentation notations? Select all that apply.

-The client slept through the night. -Abdominal wound dressing is dry and intact without drainage. -The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring frequent ambulation with a walker

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client on strict bed rest and a 24-hour urine collection

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?

A judicial decision in a court of law

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Activate the agency emergency response plan.

The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because of a belief that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which action?

Ask the nurse manager of the neurological unit to discuss the assignment.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the primary health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault

The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a child who is profoundly developmentally disabled to eat lunch

The nurse is assisting in planning client assignments. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a client to ambulate after an appendectomy

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the primary health care provider immediately. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action?

Battery

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation?

Confronting the UAP to discuss the lateness and initiate problem-solving measures

The nurse employed in a long-term care facility calls the primary health care provider (PHCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

Contact the nursing supervisor.

The nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide is higher than the recommended dosage. The nurse calls the primary health care provider to clarify the prescription and asks the primary health care provider to prescribe a dosage within the recommended range. The primary health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which action should the nurse take?

Contact the nursing supervisor.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern?

Discourage the racial comments.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?

It outlines what the organization plans to accomplish.

The nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?

Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry.

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium. After appropriately charting in the medication administration record, which action should the nurse take?

Make a notation regarding the client's refusal in the nurse's notes.

A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place the highest priority on which ongoing nursing interventions?

Monitoring the status of both mother and fetus

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

No charge will be made against the RN because the RN's actions are reasonable.

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Notify the primary health care provider of the client's request.

The nurse asks the registered nurse to call the primary health care provider (PHCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the PHCP. The PHCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the PHCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse plans to address the PHCP's remark, understanding that the PHCP has violated which legal tort?

Slander

A client has just been treated with cardioversion. The nurse should check which measure first?

Status of airway

The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's primary health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse should implement which action?

Stay with the client and consult with the nurse manager about the situation.

The nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will protect the nurse if the care given at the scene was not willfully negligent.

A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which fact?

The client cannot be forced to take the medication.

The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation?

The official power to approve an action, command an action, or to see that a decision is enforced

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?

Transport the client to the operating room immediately.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Use of padded restraints to immobilize the limb

A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

Discuss her anxieties and concerns with the nursing supervisor about floating.

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do?

Discuss the request with the primary health care provider.

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice?

Nursing personnel are led by an RN leader in providing care to a group of clients.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?

Nursing staff are led by the nurse when providing care to a group of clients.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

The nurse suspects that a coworker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to a supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

The home care nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which is the best nursing intervention for this situation?

Suggest appropriate resources such as respite care and a senior citizens' center to the client and daughter-in-law.

The nurse is observing an unlicensed assistive personnel (UAP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed?

The UAP stresses words by over enunciating them when speaking.

A client receives meperidine by the intramuscular route. Thirty minutes after receiving the medication, the client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the primary health care provider. The nurse completes an incident report and accurately documents which?

Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the primary health care provider was notified.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

Private room within sight of the nurses' station

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest?

Providing educational programs, literature, and posters to promote awareness of healthy eating

A client had a colon resection. A Salem tube was in place when a regular diet was brought into the client's room. The client did not want to eat solid food and asked that the primary health care provider be called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two meals and subsequently had additional surgery due to complications. The nurse understands that the determination of negligence in this situation is based on what?

A duty existed and it was breached

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

"They are specific guidelines."

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

A vascular surgeon repeatedly asks the nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains this to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse should appropriately manage this situation by taking which action?

Discuss the situation with the nurse manager.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent

The nurse overhears a client ask the primary health care provider if the results of a biopsy indicated cancer. The primary health care provider tells the client that the results have not returned, when in fact, the primary health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the primary health care provider has not shared the results with the client and tells another nurse that the primary health care provider has lied to the client and that this primary health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement?

Slander

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

Change the password for entering computer files at least monthly. 2.Shred the printout of the nurse's flowchart at the end of the nurse's shift. 3.Use own user name and password when logging into the computer system.

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

A postoperative client who develops a cough and a fever

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior.