Management of care from the expertsThe health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority). 1,3,5,4,2 The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? 1.All employees participate in systematically working toward common
goals The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation? 2.Request
an immediate private meeting with the health care provider and staff nurse All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first? 1.62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple
casualties. What action would the nurse take first, before the victims arrive in the ED? 1.Notify the nursing supervisor and request additional staff The nurse is caring for a client whose pain is not well controlled. Which statement
about pain management is a priority ethical consideration that can help guide the nurse? 1.The client's self-report of pain is the most important consideration A nurse receives
an illegible hand-written medication order. Which statement to the health care provider reflects assertive communication? 3."Would you please clarify what you have written so I am sure I am reading it correctly?" A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, wh 1.A female interpreter who does not know the client A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? 3.Request to see identification and an explanation as to why the woman is viewing client charts The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the 4.Page the attending physician to express the same
concerns A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse? 4.Change the assignment; reassign the client with the lumbar drain to a different nurse The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment? 2."Which groups are at the greatest risk for problems?" The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the
catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time? 1.Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowe 3.A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medication 1.The client has a right to know about the use and side effects of the prescribed medications The charge nurse is assigning duties to the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? 1.Provide stoma care for a client with a well-functioning ostomy The charge nurse reviews nursing roles and functions with a newly-hired licensed practical nurse (LPN). The LPN asks for more information about the role of the Minimum Data Set (MDS) coordinator. Which statement best explains the role of the MDS coordinat 1.Interacts with health care staff to coordinate care processes of client assessment and care
planning A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? 3.Pacemaker insertion on the
day shift A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) 1.Family preferences The MDS coordinator, who is a full time registered nurse, completes the minimum data set (MDS) for a new admission to a skilled nursing facility. Why
does the nurse complete the MDS? (Select all that apply.) 1.It provides a standardized set of essential clinical and functional status measures After working with a client, an unlicensed assistive personnel (UAP) tells the
nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? 3."He may be scared and taking it out on you. Let's talk to figure out what to do next. A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these
approaches? 2.Discuss the boundaries of a therapeutic relationship with the client The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There
is an order to discharge the client to go home today. What would be the best action for the nurse to take? 3.Collaborate with the health care provider about the change of condition The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee? 3."Let's review your skills checklist for type and level of skill for tasks." The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first? 2.A 72 year-old who returned from a right hip replacement surgery two hours ago The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical
unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) 1.The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish The nurse is named in a lawsuit. Which
of these factors will offer the best protection for the nurse in a court of law? 1.Complete and accurate documentation of assessments and interventions The triage nurse identifies that a 16 year-old client is legally married and has signed the consent form for treatment. What should be an appropriate action by
the nurse? 4.Proceed with the triage process in the same manner as any adult client The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence cou 2.The nurse could be fired for breach of confidentiality The charge nurse sends a nursing assistant to help an RN with admission of a client with multiple health problems. Which of the following tasks would be appropriate to delegate to the nursing assistant? (Select all that
apply.) 1.Collect a urine specimen The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I
have left." Which action is most appropriate? 1.Encourage the client to discuss this decision with the health care provider and family A client who is unconscious is brought to the emergency department by an ambulance.
What document should be given priority to guide the approach for the care of this client? 4.A notarized original of the advance directive brought in by the partner The 86 year-old
client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? 1.Reduce readmissions to the hospital A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first? 2.Tension pneumothorax with slight tracheal deviation to the right A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager? 3.Consult with human resources personnel about the issue and needed actions The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model? 3.Nursing departments share
responsibility for client outcomes Two new graduates are working in a busy emergency department (ED). With limited experience, the nurses may need to consult experts to assist them with client care. Which management decision impedes access to needed information? 4. Correct: Blocking access to the internet keeps employees, both experienced and inexperienced, from finding new and innovative treatments. While some employers allow access, many managers are focused on task completion and don't encourage exploration of The nurse is working in a small hospital in a rural town. A nurse from the ED calls the floor to ask about a client who was admitted from her neighborhood. The nurse answering the phone is worried that she will offend the ED nurse. What should the nurse d 2. Correct: The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation. The floor nurse should simply state the limit that she cannot give any information about a client to someone who is The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse fo 2. Correct: Health information is private. Only those who are involved with the care of the client have access to it. The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates
the action? 1. Correct: Safety must be maintained while the client is in this vulnerable state. Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Correct: This child has been receiving only liquids for more than 3 days and would be a nutritional risk. Which nurse is providing cost effective care to a client? Select all that apply: 1., 2., 3. & 4. Correct: In comparison to conventional care, palliative care is considered just as cost effective in reducing unnecessary utilization of resource. Palliative care is efficient, effective client-centered care. The nurse who begins discharge The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by his employer and his spouse. What is the best rationale for including asser 3. Correct: The client is being taught self-advocacy. The nursing role includes advocacy. This client will be discharged soon and needs improved skills for advocating for himself. The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? Select all that apply: 1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as clien A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step involves calling the primary healthcare provider. An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 2. Correct: This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. Her skin assessment indicates a circulation problem. A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply: 1., 3, & 5. Correct. These are written correctly. A client with cancer refuses treatment and asks about options for hospice home care. The clients' daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right 4. Correct: The client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? Select all that apply: 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The plate guard will prevent food fro After shift report, which client should the nurse see first? 3. Correct: The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else. A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply: 1., 2., 3., 4., & 5. Correct. Each of these actions can be taken by the nurse manager. The staff needs further education, reminders, and follow-up observation. The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restr *Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the RN delegate to an unlicensed assistive personnel (UAP)? 1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. A rape victim is admitted to the emergency department for care. The police and primary healthcare provider insist that the client consent to a rape kit examination, but the client refuses. What should the nurse do? 3. Correct: The American Nurses' Association Code of Ethics for Nurses states: "The nurse's primary commitment is to the client, whether an individual, family, group or community. The unit nurse manager would like to change the way shift report is conducted on the unit. Which activity would be most beneficial in creating this change? 3. Correct: Allowing the staff to have input and offer possible solutions is the best choice. Which member of the multi-disciplinary team oversees and
coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services t Which sign/symptom of hypoxemia in a client with pneumonia is most important for the nurse to report to the primary healthcare provider? 4. Correct: A more acute sign of hypoxemia is a change in the client's level of consciousness. Confusion is one of the acute signs of decreased arterial oxygen in the blood. The nurse overhears two nursing students
talking about a client in the cafeteria. What should the nurse do first? 3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified. Which client must the nurse assign to
a private room? 4. Correct: A temperature of 100.5 � F (38.05 � C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. A nurse on the unit
has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the manager is not caught in the middle. They will be able to come up with solutions together or the manager can med The nurse is working with a client in the home environment. The major issue of concern for the client is the prognosis for the cancer that was diagnosed three months ago. When the nurse visits, the client asks, "How do I know if what I am reading on the W 2. Correct: Websites that are authored by government agencies, educational institutions, or non-profit organizations are considered to be credible websites. Other criteria are important as well when evaluating a website. The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min; 4. Correct: When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experienc An experienced RN and LPN are working with a new graduate nurse. The graduate has just recently passed NCLEX. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor may act as a barrier to delegation? 1. Correct: The most likely reason in the described scenario is lack of experience of one of the team members. A national emergency situation exists in a small coastal town where there have been massive flooding and casualties. The damaged hospital is still receiving victims for treatment. Several nurses have volunteered to triage victims during this time. Family 4. Correct. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. The home
health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Correct: The assessment findings will allow each person to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin. A
client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? 2. Correct: This behavior must be interrupted, as the rights of other clients are being jeopardized. The other clients are being exploited by the manic client. A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response b 1. Correct: The experienced nurse demonstrates an understanding of appropriate staff supervision by answering that the charge nurses are accountable for supervising client care and safety after they have made client care assignments, and by clarifying tha Which client could the charge nurse reassign to an LPN/VN? 4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly all others could have IVF needs and medications that would require skill from an RN. Which room assignment would be most therapeutic for the nurse to make for a manic client who is hyperactive and has difficulty sleeping? 1. Correct: A private room...to decrease stimulation. Which goal is the most important for the nurse to address
for a client admitted to the cardiac rehabilitation unit? 3. Correct: On admission, the best starting point is to survey what is good and what needs to be changed. The nurse is entering data in the electronic medical record. The computer terminal is located on a rolling cart in the hallway. Which
action by the nurse is most likely to result in a possible breach of confidentiality of medical records? 4. Correct: Failing to log out may allow persons not concerned with the care of the client to access private information. A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do
first? 3. Correct: The client has the right to make decisions and to change his mind. The primary healthcare provider should be notified. The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? 3. Correct: First, the nurse will want to determine that the interventions were performed. If they were not carried out, the goal could not be achieved. A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. Correct: Assigning specific staff to client checks will assure that someone is responsible each shift, thus maintaining the client's right to a safe environment. All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to t 1. Correct: This client is at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm delivery. She is also receiving an oral tocolytic, terbutaline. The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first? 4. Correct: The client on suicide precautions should be seen first. The elderly are particularly at risk. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative floor. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks bec 4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated. What resource should the nurse consult to determine the standards of care for an institution? 3. Correct: It defines standards of care for an institution. A disoriented client is admitted to the med-surg unit with a diagnosis of acute renal failure. The client's spouse presents the nurse with an advance directive that gives instructions that no hemodialysis treatment is to be provided. What is the appropria 1. Correct: The primary healthcare provider should be informed immediately if orders conflict with the client's wishes for treatment. A copy of the advance directive should always be placed in the client's medical record. The nurse notices that the primary healthcare provider, who has been looking at his client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible o 2. Correct: It is appropriate and polite to minimize or hide the screen so that the information is no longer visible, then inquire whether the user will be returning to the computer work station. Which client should the nurse see first after receiving report on assigned clients? 1. Correct: The client reporting crushing chest pain is probably having an MI and should be seen first. This client takes priority over the other three clients. A nurse delegated ambulation of a client to the unlicensed assistive personnel (UAP). The next day, it was noted by the family that
the client was not ambulated on the nurse's shift. What delegation error was made by the nurse? 4. Correct: The nurse failed to monitor and follow up with the UAP. Supervision and evaluation are part of the 5 rights of delegation. An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this 3. Correct: The client has the right to his medical record. Generally a period of time is required to get the record copied. The client may be charged for the copy. Which assignments would be most appropriate for the RN to delegate to an LPN/VN? Select all that apply: 2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. After reviewing her assignment, the LPN/VN tells the RN her assignment is very unfair and requests that some of her clients be redistributed to the other staff.
What should the RN do? 1. Correct: Explore her concerns, this is most therapeutic. What assignment would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse her load is too heavy and that she needs to reassign at least one of her clients to another nurse. What is the best response by the charge nurse? 3. Correct: It would be best to explore the reason the RN thinks her assignment is too heavy. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units o 2. Correct: The nurse must serve as the client's advocate. This client's religion prohibits blood transfusions. An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse r 2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate. The charge nurse notices that a certain staff nurse verbally attacks a client that was admitted with a history of being sexually abused. Further investigation reveals that the staff nurse was sexually abused as a child. Which action would the charge nurse 3. Correct: The nurse does not need to be assigned to care for the client. Assigning the client to the nurse could be detrimental to the client. It would be safer for the client to be assigned to someone else. This would be fairer to the nurse and to the The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse fo 2. Correct: Health information is private. Only those who are involved with the care of the client have access to it. A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Which pr 1. Correct: The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because of decreased blood volume. The emergency department called the LDR to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 2. Correct: Obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPN/VN. Which statements should a nurse make when educating a client about advance directives? Select all that apply: 2., 3. & 4. Correct: Advance directives are legally binding documents which should be placed in the client's medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? 4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings, and to demonstrate compassion and a A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which is the best action by the nurse? 2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment. A prison inmate is brought to the emergency department. The nurse overhears another employee speaking rudely to the inmate client. Acting as the client's advocate, the nurse tells the employee privately that all clients are to be treated with equal respec 3. Correct: Every client has the right to considerate and respectful care. The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? Select all that apply: 1., 2., 3. Correct: It would be best to assign these clients to the RN as they will require more frequent assessment due to diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN The nurse delegated feeding of an elderly client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's tray is still at the bedside. What should the nurse do first? 2. Correct: Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served. The supervisor notifies the charge nurse on the pediatric floor that a 6 month old is being admitted with acute gastroenteritis. What room assignment is most appropriate for the nurse to make for this client? 1. Correct: Gastroenteritis is contagious, so if at all possible, place the child in a private room, so other children would be less likely to contract the gastroenteritis. A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. Correct: The client's family is important to her, especially her sons and their opinions regarding decisions. The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? Select all th 1., & 2. Correct: These clients are basically medical-surgical clients. A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care.
Which equipment should the case manager obtain for this client? Select all that apply: 1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unres The nurse overhears two nursing students talking about a client in the cafeteria. What
should the nurse do first? 3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified. The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the 2. Correct: This client would not be a risk and could be cared for on the antepartum/postpartum floor. A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine. Promise that you won't tell the 3. Correct: The nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired. Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 2. Correct: The child with stridor and excessive drooling is in respiratory distress from epiglottitis and should be seen first: ABCs. The RN on the unit tells the LPN/VN to perform the admission assessment on the newly admitted client. Which right of delegation did the nurse fail to consider? 1. Correct: The right task was not considered. The admission assessment must be completed by the RN. A client with an executed advance directive specifying "do not resuscitate, do not intubate" in the medical record becomes unresponsive during a bed bath. The unlicensed assistive personnel (UAP) activates the hospital code system and initiates CPR. Which 1. Correct: The nurse should immediately inform the UAP and the code team of the client's code status and ask the UAP to stop CPR. Which nurse would be the most appropriate for the charge nurse to assign to a 5 year old admitted in sickle cell crisis? 1. Correct: The nurse taking care of the appendectomy, bowel surgery, and developmentally delayed child has the set of clients that is less busy and has fewer client care needs. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence. Which tasks are appropriate for the RN to assign to the LPN/VN on a Labor, Delivery, Recovery, Postpartum Unit (LDRP)? Select all that apply: 2., 3., 4., & 5. Correct: Although the client who just delivered is still at high risk for complications, the LPN/VN can take vital signs. The RN would still need to evaluate. Breastfeeding is considered a routine teaching that the LPN/VN can reinforce on A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. What information is vital for the nurse to provide? Select all that apply: 1., 2., 3., 4., & 5. Correct: First, the nurse should identify self, agency, and client. Then deliver the Situation, Background, Assessment and Recommendation (SBAR) technique. SBAR has become the Joint Commission's stated industry best practice for stand The nurse notices that a client's bedside privacy curtain has been left partially open during the client's bath. Which is the best action for the nurse to take in order to ensure the client's right to privacy? 2. Correct: The curtain should be closed as soon as the opening is noticed to protect the client's right to privacy. The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 4. Correct: It would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected. The 3-11 shift charge nurse is making rounds on the pediatric unit. The charge nurse notes that a 12 year old admitted at 11 am was assigned to a LPN/VN during the 7-3 shift. What would be the most appropriate action by the charge nurse? 3. Correct: The nursing assessment should be completed and verified by an RN within 8 hours of admission. The nurse carrying out the assessment should initiate a plan of care as well. The nurse is preparing to discharge four clients from the unit during the shift. Which client is most likely to warrant a referral to other agencies or community outreach programs? 3. Correct: The elderly client who has limited mobility is likely to need referrals at the time of discharge, whether to physical therapy, home health, or other agency. A night shift nurse receives report from the day shift nurse when the day nurse states, "I have an appointment and I need to leave. Can you get the rest of the client's information from the medical records?" Which client right is violated by the day nurse 1. Correct: An incomplete or uninformative client report from one healthcare provider to the next violates the client's right to reasonable continuity of care. The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Correct: The client should be told about the surgical procedure, the options available,and the benefits and risks of each treatment modality. Surgery should be delayed until the client is sure of decision. What would be the most appropriate room assignment for the charge nurse to make for a school age child with seizures whose family cannot stay with the child at all times? 2. Correct: A semi-private room near the nurse's station would be the best choice for this client. A nurse from the neonatal unit is transferred to the
adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Correct: This is the most stable client to give to the nurse who was transferred from the neonatal unit. Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence. The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply: 1. & 4. Correct: Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week". After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse see first? 4. Correct: Being restless is an early sign of hypoxia. Oxygen may be necessary. Remember the ABCs. A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include in this evaluation? 1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direc Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply: 2., 3., & 5. Correct: The nurse should be given an assignment similar to the type of clients and skill level the nurse is accustomed to. Therefore, the choices should be these three clients. Even though one of the clients has leukemia, the child is being A client is to undergo an endoscopy in the client's room. The gastroenterologist asks the general medical unit nurse to prepare and then give the
client propofol 10 mL slow IVP until sedation is achieved. What action should the nurse take? 3. Correct. Propofol administration is outside the scope of practice for general floor nurses. Nurses with specialty training, particularly in critical care units, often give propofol to clients who are intubated and on the ventilator. These clients have The nurse is providing care to a client who has a history of violent episodes against
his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Correct: The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed. A primary healthcare provider has prescribed sterile saline 1.5 mL IM every
4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to primary healthcare providers. Perh A child is
admitted to the hospital with a temp of 102.2�F/ 39.0�C, lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. Which client in the Labor, Delivery, Recovery, Postpartum Unit (LDRP) should
the nurse see first? 1. Correct: Minus two stations is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. The nurse manager is having a problem on the unit with one
staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best? 3. Correct: Give the nurse an opportunity to explain and then together work on a plan of resolution. Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Correct: Yes, this client is the least critical. The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the pub 1., 3., 4. & 5. Correct: Many times factories are placed in communities where people are not aware of the hazards. The underrepresented and poor need the nurse as advocate. Forums encourage wider participation of all community members and give the communi While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 3. Correct: A new nurse should assess this client first to check her fundus. If the fundus is boggy, a fundal massage will need to be done. If the fundus is not boggy (contracted), the blood running down the legs is normal, as blood pools in the vagina wh A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book crushing the tablet and mixing it into 3 ounces of applesauce, the student nurse proceeds to the client's room. What priority action should the 2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may n The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurs 4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shin A nurse wants to find a better way to
perform oral care on unresponsive clients. What is the first action for the nurse to take in order to achieve this goal? 2. Correct: The best thing for the nurse to do is to identify a problem, as this is the person directly caring for clients. Then, get with an experienced person who can research "best practice" regarding the issue. A new nurse is
documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply: 1., 3, & 5. Correct. These are written correctly. An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this act 1. Correct: The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and to foster a sense of security. A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 3. Correct: The nurse is the only one who can assess. The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be inappropriate for the nurse to assign to the LPN/VN? 4. Correct: This client has adrenal insufficiency. It occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones are lacking. This puts the clien A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 3. Correct: The best action by the nurse would be to itemize the valuables, place in an envelope, and put in the hospital safe. The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? Select all apply: 4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. Which members of the multidisciplinary team should the nurse recognize as being responsible for collaboration in client care? Select all that apply: 1., 2., 3., 4., & 5. Correct: All members of the multidisciplinary health care team are responsible for a collaborative care approach to client care. Multidisciplinary care has significantly improved client outcomes and decreased client length of stay in The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources 2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. Correct: This client needs a private room so she can feel free to grieve and have family members stay with her for support. She should be transferred to a GYN unit so the sights and sounds of the maternity unit do not contribute to her pain. Case managers use clinical pathways in the process of evaluating and coordinating client care with the multidisciplinary team. What is a clinical pathway? 4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care. The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the
nurse do? 1. Correct: The client should be told about the surgical procedure, the options available,and the benefits and risks of each treatment modality. Surgery should be delayed until the client is sure of decision. Which client should the labor nurse see first? 4. Correct: A systolic blood pressure of ? 140 mmHg or a diastolic BP of ? 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? 2. Correct: Measurement of intake and output is a function of an unlicensed assistive personnel, and these tasks may be delegated. The nurse is supervising the care of a client with a closed head injury. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Correct: Stop this. No valsalva as this will increase ICP. TCDB increases intrathoracic pressure which increases ICP. The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Correct: The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed. A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this 4. Correct: This client has symptoms of preeclampsia and should be either in a private room or in a quiet, darkened room to minimize stimuli that could trigger seizures. A roommate requiring a similar environment would be most appropriate when there are n The home health nurse has been working with an elderly African American woman for six months. Recently, she has become withdrawn and is not attending church. The client had previously spoken to the nurse about the importance of faith in her life. The nurs 3. Correct: The client may benefit from involvement of the minister. Perhaps the client needs transportation to church, or needs increased contact with the church family. Church is typically important to the African American client A nurse assigned to an HIV-positive client refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 2. Correct: Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have in The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks beca 4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated. Which pediatric client should the nurse see first? 3. Correct: The child having respiratory difficulty should be seen first. The nurse is taking report on a busy unit. The nurse recognizes that three admissions were taken during the night shift, one nurse called in sick, and the clients on the unit are very ill. What action should the nurse do first to
ensure client safety? 4. Correct: The nurse should call for immediate help so that a safe care environment is maintained for all clients. The nursing supervisor may be able to lend a hand until another nurse can come in to work. The nurse suspects that a neighbor is abusing their child. The nurse has noticed bruises on the child's face, the backs of the hands, and the tops of the feet. When questioned, the parents state their child is just clumsy. The nurse reports possible abuse 1. Correct: The action is appropriate. The nurse is serving as an advocate for the child who cannot advocate for self. A nurse delegated ambulation of a client to the unlicensed assistive personnel (UAP). The next day, it was noted by the family that the client was not ambulated on the nurse's shift. What delegation error was made by the nurse? 4. Correct: The nurse failed to monitor and follow up with the UAP. Supervision and evaluation are part of the 5 rights of delegation. The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Correct: This group of clients is primarily med surgical. Who often performs the responsibilities of a case manager? Select all that apply: 2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional. A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how
to do it while in nursing school. What would be the best action by this nurse? 2. Correct: The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with another nurse and ask the nurse to observe during Which ethical principle is involved when a nurse reports a
medication error to the primary healthcare provider? 1. Correct: Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented. Which action by a nurse would require the charge nurse to intervene? 1. Correct: The area outside the OR is restricted to personnel with surgical attire and coverings. A newly appointed nurse manager on the renal unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemente 1. Correct: Yes, get everyone together and discuss the problem and find areas of compromise where possible. The nurse is working in a small hospital in a rural town. A nurse from the ED calls the floor to ask about a client who was admitted from her neighborhood. The nurse answering the phone is worried that she will offend the ED nurse. What should the nurse d 2. Correct: The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation. The floor nurse should simply state the limit that she cannot give any information about a client to someone who is The nurse notices that the primary healthcare provider, who has been looking at his client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible o 2. Correct: It is appropriate and polite to minimize or hide the screen so that the information is no longer visible, then inquire whether the user will be returning to the computer work station. The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what s 2. Correct: The nurse should carefully assess the client. The nurse must serve as an advocate for the client. |
Which action by the emergency department (ed) nurse warrants intervention by the charge nurse?
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