A nurse is assisting with the selection of clients to discharge to make beds available following a tornado in the community. Which of the following
... [Show More] clients should the nurse recommend for discharge?
• A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago
RATIONALE: A client who had an appendectomy without complications is often discharged the day of
or the day after surgery. The nurse should recommend this client for discharge because this client has a low risk for an adverse event.
A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first?
• A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent
RATIONALE: A client who has a pelvic crush injury and an absent pulse to the lower extremity has an
immediate threat to life and limb and requires emergent care for survival. When using the survival approach to client care, the nurse should give priority to this client.
A nurse is contributing to the plan of care for a client who states he is a devout Hindu. To adhere to the client’s religious dietary practices, which of the following food options should the nurse offer to the client?
• Yogurt
RATIONALE: The nurse should offer yogurt as a food option for the client who is a devout Hindu because dairy products are believed to enhance spiritual purity.
A nurse assisting with disaster triage is examining a client who has a large open would to the lower extremity. Which of the following actions should the nurse take?
• Tell the client she should receive treatment within 2 hr.
RATIONALE : When performing disaster triage, the nurse should assign clients who have a large, open wound to the yellow, or urgent category. This is the second-priority client category, and clients who are in this category should receive treatment after the emergent group, but within 30 min to 2 hr.
A nurse is verifying informed consent with a client who is scheduled to have a total open abdominal hysterectomy with bilateral salpingo oophorectomy for the treatment of
uterine cancer. The nurse should notify the provider for which of the following client statements?
• "I wish I knew if there was another way to treat this other than surgery."
RATIONALE : The nurse should contact the provider to clarify the procedure and other options with the client. It is the provider's responsibility to inform the client of any other treatment options.
A nurse is planning to delegate care for a group of clients following change-of-shift report. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)?
• Applying bilateral sequential compression devices to a client's legs
RATIONALE : The nurse should delegate applying sequential compression devices to an AP because this skill is used routinely in client care, creates minimal safety risk for the client, and is within the range of function for an AP.
A nurse is discussing the meaning of utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this ethical theory?
• "Utilitarianism provides the greatest good for the greatest number of people."
RATIONALE : The nurse indicates an understanding of the ethical theory of utilitarianism by stating that the basis for this theory provides the greatest good for the greatest number of people.
A nurse is assisting with a presentation about preparing a home disaster supply kit at a community health fair. Which of the following statements by a participant should the nurse identify as understanding of the information?
• "I will purchase canned fruit for the kit."
RATIONALE - A home disaster kit should include nonperishable food items, which require no cooking or preparation and little water. Therefore, the nurse should identify the inclusion of canned fruit as an understanding of the information.
A nurse is delegating collection of a random stool specimen to an assistive personnel (AP). Which of the following information should the nurse provide?
• Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal.
RATIONALE -The nurses should instruct the AP to use one to two tongue blades to move the stool specimen to the collection container. After transferring the stool, the AP should wrap the tongue blades in a paper towel before discarding them in the trash to prevent others from accidentally touching the contaminated surfaces.
A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients?
• A client who has burns to the trunk and legs
RATIONALE -The nurse should expect this client to have a yellow tag because this client's injuries require treatment that can be delayed.
A nurse is contributing to the plan of care for a group of clients. Which of the following scenarios demonstrates effective use of time management techniques?
• The nurse groups activities for a surgical client based on the client's pain medication schedule.
RATIONALE -The nurse should anticipate when the client will need pain medication and schedule care activities at a time when the client is most comfortable and able to move, which will assist the client to meet goals and allow the nurse to plan care more effectively.
A charge nurse in a skilled care facility identifies an increased rate of client falls. Which of the following statements to the nursing staff indicates the charge nurse is addressing the problem with an autocratic leadership style?
• "I've made it mandatory for all nursing staff to attend an educational session on reducing client falls."
RATIONALE -This statement indicates an autocratic style of leadership. An autocratic leader makes independent decisions about how to address a problem without seeking input from nursing staff.
A nurse in a long-term care facility is caring for a client who is refusing his prescribed medications. Which of the following actions should the nurse take first?
• Identify the client's concerns about taking the medications.
RATIONALE -The first action the nurse should take when using the nursing process is to collect data from the client. By identifying the client's concerns and reasons for refusing the medications, the nurse can determine which actions to take next to prevent worsening of the client's condition.
A nurse is observing an assistive personnel (AP) provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks?
• Making a surgical bed for a client returning from surgery
RATIONALE -Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, such as blood or wound drainage. It is not necessary to use gloves when making an unoccupied surgical bed.
Therefore, this is a waste of supplies and requires intervention by the nurse.
A nurse is assisting with the discharge of a client who was in a motor-vehicle crash 24 hr ago. The client tells the nurse, “My vision seems blurry, and I am having difficulty speaking clearly.” Which of the following actions should the nurse take first?
• Check the client for indications of increased intracranial pressure.
RATIONALE -The first action the nurse should take using the nursing process is to collect data from the client. By checking the client for indications of increased intracranial pressure, the nurse can determine if the client has any neurological deficits and identify findings to report to the charge nurse and the provider.
A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse include?SATA
• Administer furosemide 40 mg PO daily is correct. A client who has heart failure can benefit from a loop diuretic, such as furosemide, to reduce pulmonary and peripheral edema.
• Apply oxygen to keep SpO2 greater than 95% is correct. A client who has heart failure might
require supplemental oxygen to maintain an adequate SpO2 level. A SpO2 greater than 95% is an acceptable outcome.
Obtain daily weight is correct. The nurse should obtain a daily weight for a client who has heart failure to provide data about fluid balance.
A newly hired nurse recognizes that the unit staff and the nurse manager seem to be in constant conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches when she decides that her plans are best and the unit staff is no longer trying to resolve conflict?
• Win-Yield
RATIONALE -The nurse should identify the unit is using the win-yield approach to conflict management. With this approach, the manager is always right and the staff is no longer trying to resolve conflict, which creates an oppressed working environment on the unit.
A nurse is assisting with the care of an older client who is recovering from a stroke and is experiencing difficulty swallowing and performing ADLs. The client will be living with his adult son following discharge. The nurse should recognize that which of the following client referrals has the highest priority?
• Speech therapy
RATIONALE -When using the safety vs. risk reduction approach to client care, the greatest risk to this client is aspiration and airway compromise from difficulty swallowing. Therefore, the priority referral is for speech therapy. A speech therapist specializes in evaluation, management, and improvement of swallowing difficulties.
A nurse is assisting with the admission of a client who reports that she signed advance directives during previous admission. Which of the following actions should the nurse take?SATA
• Document in the client's medical record that she has advance directives is correct. According to the Patient Self-Determination Act, the client's medical record should indicate whether or not she has advance directives.
Ensure that copies of the client's advance directives are located in her chart is correct. Having copies of the client’s advance directives in the medical record ensures that the health care team is aware of her wishes regarding health care decisions.
Inform the oncoming nurse of the client's advance directives during change-of-shift report is correct. The nurse should discuss the client's advance directive status with nurses who will be directly providing client care.
A nurse is collecting data from a client following abdominal surgery. The nurse should recognize which of the following client findings is the priority to report to the provider?
• Surgical dressing saturated with bloody drainage
RATIONALE -When using the airway, breathing, and circulation approach to client care, the nurse determines that the priority finding to report to the provider is the surgical dressing saturated with bloody drainage. This finding indicates the client is possibly experiencing postoperative hemorrhage, which can lead to hypovolemia and shock.
A charge nurse is discussing legal issues with a newly licensed nurse. Which of the following actions should the charge nurse identify as negligence?
• Failing to provide one-to-one observation for a client who is suicidal.
RATIONALE -Failure to provide care according to established standards of care is negligence. Failing to provide one-to-one observation to a client who is suicidal puts the client at risk for self-injury.
A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides?
• Use sentences that have a maximum of six words.
RATIONALE -When developing effective slides for a slide presentation, the nurse should keep sentences short and limit the number of words to five or six per sentence.
A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first?
• A preschooler who has respiratory syncytial virus and is wheezing
RATIONALE -When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority client is the preschooler who is wheezing because this client is at risk for a possible airway obstruction.
A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first?
• Verify the medication with the client's medication administration record (MAR).
RATIONALE -Evidence-based practice indicates the first action the nurse should take when administering ophthalmic medication is to validate the client's name, the name and dosage of the medication, and the medication prescription, route, and time with the client's MAR.
A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for a client at home?
• Portable suction
RATIONALE -The nurse should ensure that a portable suction device and other suctioning equipment is available in the home to clear respiratory secretions.
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