A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written
... [Show More] informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?
"Procedures prescribed by the provider do not require consent." "This is a procedure that does not require written informed consent." • "You are right. I will discuss this issue with the charge nurse."
"Would you mind signing the informed consent form for the procedure at this time?"
A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?
Instruct a client how to take their blood pressure. Administer subcutaneous medications to a client. Determine a client's intake and output. •
Provide a status update to a client's family member.
A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?
Child protective services Public health
• Home health
Women, Infants, and Children
A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next.
Set target dates for completion. Identify areas of support.
Determine goals and objectives. • Implement recommended strategies
A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?
Digoxin 1.0 ng/mL •
WBC 6,000/mm3
Platelets 100,000/mm3 Serum potassium 4.0 mEq/L
A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?
The child has red sores at the corners of the mouth. The child has several small bruises on both legs.
The child sleeps for about 13 hr each night. The child is not regularly attending school
A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?
"Change-of-shift report can be given at the client's bedside."
"I can provide client information over the phone if the caller identifies themselves as family." "A client cannot see their medical record because it is considered to be property of the facility." "Access to client information is limited to direct care providers."
A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?
A nurse is photocopying their assigned client's diagnostic test results. •
An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record.
The unit secretary faxes a client's laboratory results to the provider.
An RN stays with a client who is reading the medical records that were requested.
A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?
The age of the client
The availability of community support groups • The length of the client's stay
The type of insurance the client carries
A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.)
The right to be treated with respect and dignity The right to full access of the facility
The right to refuse their medications
The right to leave regardless of provider recommendations The right to be fully informed of their health conditions
A nurse on a medical-surgical unit has arrived late to work multiple times over the past several weeks. Identify the sequence the nurse manager should follow when disciplining the employee. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Schedule a meeting with the nurse. Provide a written reprimand.
Temporarily remove the nurse from scheduled shifts. Terminate the nurse's employment.
Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?
"Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122." "Check the urinary output at 1100 for John Doe and report it to me immediately." "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438."
"Please notify me of any clients whose vital signs or blood glucose levels are significant."
A nurse is caring for a 19-year-old client who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make?
"I will have the provider discuss treatment options with your parents." "I will gather information about palliative care for you." •
"I will contact your spiritual advisor to discuss this decision with you."
"I will contact your parents about becoming your designees in your durable power of attorney."
A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?
The nurse places the sterile package with the top ap opening away from the body. • The nurse pinches the ap on the inside of the package rst to open it.
The nurse reaches over the package to open the left ap.
The nurse pulls the last ap of the package away from the body.
A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?
Request crutches from a medical equipment provider. Advise the client to install grab bars in the bathroom at home.
Encourage the client to allow a home care aide to perform ADLs for them. • Contact hospice to provide follow-up care for the client.
A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to an LPN?
A. Determine the swallowing ability of a client who has had a stroke. B. Provide an enteral feeding to a client who has Chron's disease.
C. Develop a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus.
D. Weigh a client who is 3 days postoperative following coronary artery bypass grafting.
A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?
"A social worker will address your concerns after discharge."
"You should plan to go to a skilled nursing facility after discharge." "Your case manager will coordinate the resources you will need." • "You will need hospice care until you feel stronger."
A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take?
Report the findings to the hospital ethics committee. Alert central supply.
Fill out an incident report.
Notify the quality improvement team.
A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take?
Assist in weighing the options involved in the decision. Provide a legal representative for the family.
Recommend the best course of action for the client. Decide how the nursing team should resolve the dilemma.
A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?
A client who is in balanced skeletal traction
A client who had a total hip arthroplasty 3 days ago A client who has a fractured femur with a new cast
A client who had a right above-the-knee amputation 24 hr ago
A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?
Take extra wheelchairs to the emergency department. Send PACU assistive personnel to assist with triage. Identify stable clients for transfer to a surgical unit. Report to the command center for further instructions.
A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 min. The nurse is demonstrating which of the following ethical principles?
Beneficence
Utility Justice Fidelity
A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion?
Interpreter • Social worker
Occupational therapist Spiritual advisor
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 actions should the newly licensed nurse take?
Open the top ap of the sterile package towards the body.
Maintain a 1.25 cm (0.5 in) border around the edges of the sterile end. Pick up the first sterile glove by grasping the folded cu edge.
Remove soiled dressings using sterile gloves.
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 nurse that he will not have the surgery. Which of the following actions should the nurse take?
Inform the client of the consequences of decreased cerebral circulation.
Initiate a mental health consultation to determine why the client refuses the surgery. Discuss the client's concerns about having the surgery.
Provide the client with information on additional treatment options.
A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include?
Raise the footplates of the wheelchair before transferring the client. Lock the brake on one wheel of the chair when transferring the client. Push the wheelchair into the elevator with the front wheels first.
Stand behind the wheelchair when moving a client down a ramp.
A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"A nurse can provide basic treatment information to the client's employer."
"A nurse can inform the client about the risks and benefits of electroconvulsive therapy."
"Clients on a mental health unit who are admitted voluntarily cannot leave against medical advice."
"Clients on a mental health unit can refuse their medication."
A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?
"The client who had abdominal surgery 3 days ago is reporting feeling constipated." "The client who had the hip replacement reports pain as 4 on a scale of 0 to 10."
"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void."
"The client who is scheduled for discharge today states they are ready to sign their paperwork."
A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?
"It sounds like nonpharmacological interventions would be best for this client." "Let's withhold the oxycodone until we can consult with the provider." "Contact mental health services to arrange for a consultation."
"Clients are the experts on their own pain."
A nurse is caring for four clients. Which of the following assessment findings is the priority?
A client who has facial drooping following a stroke 8 hr ago
A client who has a femur fracture and reports feeling short of breath
A client who had an appendectomy 12 hr ago and reports pain as 5 on a scale of 0 to 10
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing
A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the sta begin tube feedings. Which of the following actions should the nurse take?
Insert the tube and begin feedings per the family's request. Ask the provider to discuss the issue with the family.
Report the dilemma to the facility's dietitian. Review the client's request with the family
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?
Conduct an in-service that reviews proper catheter insertion and maintenance. Perform a chart review to gather data about the clients who developed infections. Observe each staff nurse perform a urinary catheter insertion.
Require completion of a self-paced instruction program.
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?
Compare data from clients' records regarding skin integrity with established criteria. Measure staff attendance at an educational program on managing pressure injuries. Interview clients regarding their satisfaction with their care.
Monitor use of supplies used to prevent pressure injuries.
A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?
National League for Nursing (NLN) American Academy of Nursing (AAN)
Agency for Healthcare Research and Quality (AHRQ) State Nurse Practice Act (NPA)
A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue?
Inform the staff of the penalties that can result from medication errors. • Encourage the staff to have two nurses verify medication orders to prevent errors. Provide a suggestion box for the staff to submit ideas for error prevention.
Ask three experienced nurses to help investigate common causes of the errors
A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?
Place the client on droplet precautions.
Place the client in a room with positive pressure airflow. Wear a surgical mask when taking the client out of the room. Wear an N95 respirator mask when in the client's room.
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?
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