1) A nurse enters the room of a client who is on contact precautions and find the client lying on the floor. Which of the following actions should the
... [Show More] nurse take first?
A. Call the provider.
B. Ask a staff member for assistance getting the client back in bed.
C. Inspect the client for injuries.
D. Instruct the client to ask for help if he needs to get out of bed.
C. Inspect the client for injuries.
2) An RN on a medical surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN?
A. Obtain vital signs for a client who is 2 hr post procedure following a cardiac Catherine station.
B. Administer a unit of packed red blood cells to a client who has cancer.
C. Instruct a client who is scheduled for discharge in the performance of one care.
D. Develop a plan of care for a newly admitted client who has pneumonia.
A. Obtain vital signs for a client who is 2 hr post procedure following a cardiac Catherine station.
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3) A PN ending her shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following action should the RN take?
A. Complete an incident report.
B. Delegate this task to the PN.
C. Ask the AP if she needs assistance.
D. Notify the nurse manager.
C. Ask the AP if she needs assistance.
4) A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information to the manager include in the plan? Select all that apply
A. Skilled proficiency.
B. Assignment to a preceptor.
C. Budgetary principles.
D. Computerized charting.
E. Socialization into unit culture.
F. Facility policies and procedures.
A. Skilled proficiency.
B. Assignment to a preceptor.
D. Computerized charting.
E. Socialization into you in a culture.
F. Facility policies and procedures.
The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse.
5) A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should a nurse manager include? Select all that apply
A. A structure audit evaluates the setting and resources available to provide care.
B. An outcome audit evaluate the results of the nursing care provided.
C. A root cause analysis is indicated when a sentinel event occurs.
D. Retrospective audits are conducted while the client is receiving care.
E. After data collection is completed, it is compared to a benchmark.
A. A structure audit evaluates the setting and resources available to provide care.
B. An outcome evaluate the results of the nursing care provided.
C. A root cause analysis is indicated when a sentinel event occurs.
E. After data collection is completed, it is compared to a benchmark.
6. A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure?
A. Frequency with which procedure is performed
B. Client satisfaction with performance of procedure
C. Incidence of complications related to procedure
D. Accurate documentation of how procedure was performed
C. Incidence of complications related to procedure.
7) A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating?
A. Avoidance.
B. Smoothing.
C. Cooperating.
D. Negotiating.
Avoidance
8) A nurse is preparing to transfer an older adult client who is 72 hours postoperative to a long-term care facility. Which of the following information should the nurse include in the transfer report? Select all that apply
A. Type of anesthesia used.
B. Advanced directive status.
C. Vital signs on day of admission.
D. Medical diagnoses.
E. Need for specific equipment.
B. Advanced directive status.
D. Medical diagnoses.
E. Need for specific equipment.
9) A nurse is participating in an inter-professional conference for a client who has a recent C6 spinal cord injury. The client worked as a construction worker prior to his injury. Which of the following members of the interprofessional team should participate in planning here for this client? Select all that apply
A. Physical therapist.
B. Speech therapist.
C. Occupational therapist .
D. Psychologist.
E. Vocational counselor
A. Physical therapist.
C. Occupational therapist .
D. Psychologist.
E. Vocational counselor
10) A nurse manager is working with a committee of nurses to update the policies for new employee orientation. The nurse manager directs the team to collect as much data as possible and recommend several options. Which of the following decision making styles is the nurse manager demonstrating?
A. Decisive.
B. Flexible.
C. Hierarchical.
D. Integrative.
D.
When the integrative decision making style is used, the team uses a large amount of data and generate several options.
Decisive: the team uses a minimal amount of data and generate one option.
Flexible: the team uses a limited amount of data and generates several options.
Hierarchical: the team uses a large amount of data and generates one option.
11) A nurse who has just assumed the role of unit manager is examining her skills in interprofessional collaboration. Which of the following action support the nurse's interprofessional collaboration? Select all that apply
A. Use aggressive communication when addressing the team.
B. Recognize the knowledge and skills of each member of the team.
C. Ensure that a nurse is assign to serve as the group facilitator for all interprofessional meetings.
D. Encourage the client and family to participate in the team meeting.
E. Support team member request for a referral.
B. Recognize the knowledge and skills of each member of the team.
D. Encourage the client and family to participate in the team meeting.
E. Support team member request for a referral.
12) A nurse on a telemetry unit is caring for a client who was admitted 2 hours ago and has chest pain. The client becomes angry and tells the nurse that there is nothing wrong with him and that he is going home immediately. Which of the following actions should the nurse take? Select all that apply
A. Notify the client's family of his intent to leave the facility.
B. Document that the client left the facility against medical advice (AMA).
C. Explain to the client the risk involved if he chooses to leave.
D. Ask the client to sign a form relinquishing responsibility of the facility.
E. Prevent client from leaving the facility on to the provider
B. Document that the client left the facility against medical advice (AMA).
C. Explain to the client the risk involved if he chooses to leave.
D. Ask the client to sign a form relinquishing responsibility of the facility.
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13) A nurse manager is observing the actions of a nurse she is supervising. Which of the following actions by the nurse requires the nurse manager to intervene? Select all that apply
A. Reviewing the healthcare record of a client assigned to another nurse.
B. Making a copy of a clients most current laboratory results for the provider during rounds.
C. Providing information about the clients condition to hospital clergy.
D. Discussing a clients condition over the phone with an individual who has provided the clients information code.
E. Participating in walking rounds that involve the exchange of client related information outside clients room.
A. Reviewing the healthcare record of a client assigned to another nurse.
B. Making a copy of a clients most current laboratory results for the provider during rounds.
C. Providing information about the clients condition to hospital clergy.
E. Participating in walking rounds that involve the exchange of client related information outside clients room.
14) A nurse is caring for a client who is scheduled for surgery. The client Hands the nurse information about advance directives and states, "here, I don't need this. I am too young to worry about life-sustaining measures and what I want done for me." Which of the following actions should the nurse take?
A. Return the papers to the admitting department with a note stating that the client does not wish to address the issue at this time. B. Explain to the client that you never know what can happen during surgery and that he should fill the papers out just in case.
C. Contact a client representative to talk with the client and offer additional information about the purpose of advance directives.
D. Informe the client that the surgery can't be conducted unless he completes Advance directive forms.
C. Contact a client representative to talk with the client and offer additional information about the purpose of advance directives.
The nurse should advocate for the client by ensuring that the client understands the purpose of advance directives. Seeking the assistance of a client representative to provide information to the client is an appropriate action.
15) A nurse witnesses an assistive personnel (AP) under her supervision reprimanding a client for not using the urinal properly. The AP threatens to put a diaper on the client if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
A. Assault.
B. Battery.
C. False imprisonment.
D. Invasion of privacy.
Assault
Assault is conduct that makes a person fear he or she will be harmed.
16) A nurse is serving as a preceptor to a newly licensed nurse and is explaining the role of the nurse as advocate. Which of the following situations illustrates the advocacy role? Select all that apply
A. Verifying that a client understands what is done during a cardiac catherization.
B. Discussing treatment options for a terminal diagnosis.
C. Informing members of the healthcare team that a client has do not resuscitate status.
D. Reporting that a health team member on the previous shift did not provide care as prescribed.
E. Assisting a client to make a decision about his care based on the nurses recommendations.
A. Verifying that a client understands what is done during a cardiac catherization.
C. Informing members of the healthcare team that a client has do not resuscitate status.
D. Reporting that a health team member on the previous shift did not provide care as prescribed.
17) A nurse manager is providing information to the nurses on the unit about ensuring client rights. Which of the following regulations outlines the rights of individuals in healthcare settings?
A. American Nurses Association code of ethics.
B. HIPAA.
C. Patient self determination act.
D. Patient care partnership.
D. Patient care partnership.
Document that addresses clients rights when receiving care.
ANA code of ethics provides nurses with a set of standards for nursing practice.
HIPAA Insurance client privacy and confidentiality.
The patient self-determination act is a federal legislation that requires that all client admitted to healthcare facility be asked whether they have advanced directives.
18) A newly licensed nurse is preparing to insert an IV catheter in a client. Which of the following sources should a nurse to use to review the procedure in standard at which it should be performed?
A. Website.
B. Institutional policy and procedure manual. C. More experienced nurse.
D. State nurse practice act.
B. Institutional policy and procedure manual.
19) A nurse is reviewing a client's healthcare record and discovers that the client's do not resuscitate (DNR) prescription has expired. The clients condition is not stable. Which of the following actions should the nurse take?
A. Assume that the client does not want to be resuscitated, and take no action if she experiences cardiac arrest.
B. Write a note on the front of the provider prescription sheet asking the DNR be re-prescribed.
C. Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest.
D. Call the provider to determine whether the prescription should be immediately reinstated.
D. Call the provider to determine whether the prescription should be immediately reinstated.
Action to take to be sure that the client's wishes are carried out.
20) A nurse is caring for a toddler who is being treated in the emergency department following a head concussion from a fall. History reveals the toddler lives at home with only her mother. The mother's discharge instructions include waking the child every hour to assess for indications of a possible head injury. In which of the following situations should a nurse intervene in attempt to prevent discharge?
A. The mother states she does not have insurance or money for a follow up visit.
B. The child states her head hurts and she wants to go home.
C. The nurse smells alcohol on the mother's breath.
D. The mother verbalizes fear about taking the child home and requests she be kept overnight.
C. The nurse smells alcohol on the mother's breath.
It will be unsafe to discharge a toddler who requires hourly monitoring with a mother who might be chemically impaired.
21) A home health nurse is assessing the safety of a clients home. The nurse should identify which of the following factors as increasing the clients risk for falls? Select all that apply
A. History of a previous fall.
B. ReduceReduced vision.
C. Impaired memory.
D. Takes rosuvadtatin.
E. Uses a nightlight.
F. Kyphosis
A. History of a previous fall.
B. ReduceReduced vision.
C. Impaired memory.
F. Kyphosis
22) A nurse on an acute care unit is caring for a client following a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocated the new hip joint, and he repeatedly attempts to get out of bed. After determining that restraint application is indicated, which of the following actions should the nurse take? Select all that apply
A. Secure the restrain to the frame of the bed. B. Get in prescription for restraint from the provider.
C. Have a family member signed the consent form strains.
D. Use a square knot to secure the restraint to bed.
E. Ensure that only one finger can be inserted between the restraint and the client.
A. Secure the restrain to the frame of the bed. B. Get in prescription for restra [Show Less]