A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the
... [Show More] nurse that he will not have the surgery. Which of the following actions should the nurse take?
A. Inform the client of the consequences of decreased cerebral circulation.
B. Initiate a mental health consultation to determine why the client refuses the surgery.
C. Discuss with the client his concerns about having the surgery.
D. Provide the client with information on additional treatment options.
A charge nurse notices a newly hired nurse consistently does not finish client care tasks by the end of the shift. Which of the following statements should the charge nurse make?
A. "You should set aside time to plan your day at the beginning of each shift."
B. "You should not take a break until all of your tasks are completed."
C. "You should leave your hardest task for the end of the shift."
D. "You should save your charting for the end of the shift."
Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should recognize that which of the following is an appropriate approach to this conflict?
A. Schedule the nurses to work on alternating shifts.
B. Organize a task force to evaluate the situation.
C. Tell the nurses that it is their responsibility to cooperate with coworkers.
D. Explore alternative solutions to address unit workflow with the nurses.
A charge nurse is conducting an in-service with staff members about infection control precautions. The nurse should instruct the staff that which of the following clients requires droplet precautions?
A. A client who has shigella.
B. A client who has measles.
C. A client who has toxic shock syndrome
D. A client who has pertussis.
A nurse in the emergency department is admitting clients following an eartquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualities. Which of the following clients should the nurse recommend the provider evaluate first?
A. A client who has a penetrating head injury and respirations of 4/min.
B. A client who has a comminuted fracture of the femur.
C. A client who has a 6-inch laceration to the scalp with clotted blood visible.
D. A client who has a sucking chest wound.
A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse?
A. A client who has heart failure and 2+ edema of her lower extremities.
B. A client who is 2 days postoperative and has a urine output of 20 mL/hr
C. A client who started taking verapamil and has a heart rate of 75/min.
D. A client who is receiving morphine and reports nausea.
A nursing unit is undergoing changes to accomodate new bariatric services that will be available to the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take? (Select all that apply)
A. Role model a positive approach to the changes.
B. Redirect the conversation when staff members make negative comments about the changes.
C. Encourage staff members who support the changes to discuss the issue with resistant staff.
D. Suggest that resistant staff members transfer to a different unit.
E. Reprimand staff members who are resistant to the changes.
A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the confrence?
A. The client does not have transportation for discharge home.
B. The client refuses to attend physical therapy sessions.
C. The client's home health nurse has not completed the home assessment.
D. The client describes feelings of depression after his family visits.
A charge nurse is evaluating a plan of care that a novice nurse developed for a client who is to receive a continuous NG tube feeding. Which of the following interventions should the charge nurse ensure is part of the plan of care?
A. Flush the tube every 8 hours with 0.9% sodium chloride irrigation.
B. Use an acidic juice to unclog a blocked tube.
C. Add dissolved medications to the enteral feeding.
D. Use a 60 mL syringe to flush out a clogged tube.
A nurse has just received report on four clients on a medical-surgical unit. Which of the following clients should the nurse plan to assess first?
A. A client who has COPD and an oxygen saturation level of 92%.
B. A client who is postoperative following a total knee arthroplasty and has a capillary refill of 4 seconds.
C. A client who has diabetes mellitus and a blood glucose of 150 mg/dL
D. A client who is 12 hr postoperative following abdominal surgery and has absent bowel sounds.
A nurse is teaching a newly licensed nurse about the guidelines for obtaining a telephone prescription from a provider. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I should repeat the prescription back to the provider for verification."
B. "I should have the pharmacist contact the provider to obtain a new prescription."
C. "The provider does not have to sign a presciption if the pharmacist approves it."
D. "The provider may leave telephone prescriptions with a student nurse if a licensed nurse is unavailable."
A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?
A. Assist clients who are in immediate danger to a safe location.
B. Close doors and windows on the unit.
C. Attempt to extinguish the fire using an ABC fire extinguisher.
D. Discontinue oxygen use for clients who can breathe without it.
A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care?
A. Provide the client with information about advance directives.
B. Tell the client's partner to complete advance directives on his behalf.
C. Notify the facility chaplain of the client's needs for advance directives.
D. Tell the client that his provider will complete a health care proxy form for him.
A nurse manager is completing a performance improvement audit and determines documentation of client discharge teaching is below the expected benchmark. Which of the following actions should the nurse implement first?
A. Offer incentives for the staff once the unit's benchmark is above average.
B. Train specific nurses to use a standard discharge teaching plan.
C. Determine the factors that interfere with the documentation of client education.
D. Include client discharge teaching as part of the annual performance evaluation.
A nurse overhears two staff members in the facility elevator discussing a client's care. Which of the following interventions should the nurse take?
A. Clarify the client information the staff members are discussing.
B. Inform the client's provider of the incident.
C. Report the incident to the nurse manager.
D. Tell the client about overhearing a discussion regarding his care.
A nurse case manager is planning a teaching session on the use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following information in the teaching?
A. Critical pathways promote individualized care.
B. Critical pathways decrease administrative work time.
C. Critical pathways prevent unnecessary expense.
D. Critical pathways incorporate provider preferences.
A nurse is providing change-of-shift report to the oncoming nurse. Which of the following information shuold the nurse include?
A. Subjective comments about the client.
B. Routine morning care the nurse provided.
C. The client's insurance provider.
D. The time of the client's last pain medication
A nurse is caring for an older adult client who has renal failure. The client tells the nurse that he has decided to stop hemodialysis treatment. Which of the following actions should the nurse take to act in the role of the advocate for the client?
A. Inform the client that many clients receiving hemodialysis face discouragement.
B. Support the client's decision regarding treatment.
C. Tell the client that he made the right decision.
D. Suggest that the client's family advocate for continued treatment.
A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?
A. Conduct an in-service that reviews proper catheter insertion and maintence.
B. Perform a chart review to gather data about the clients who developed infections.
C. Observe each staff nurse perform a urinary catheter insertion.
D. Require completion of a self-paced instruction program
A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following is an appropriate action by the newly licensed nurse?
A. Opens the top flap of the sterile package toward herself.
B. Maintains a 1.25 cm (1/2 in) border around the edges of the sterile field
C. picks up first sterile glove by grasping the folded cuff edge.
D. Removes soiled dressings using sterile gloves
A nurse is preparing to administer medication to a client who has Crohn's Disease. The client states, " I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?
A. Leave the medication on the client's bedside table to take later.
B. Return in 1 hour to administer the medication.
C. Mix the medication in applesauce to administer to the client.
D. Inform the client of the consequences of refusing the medication [Show Less]