An RN has to teach the client initially but can delegate ________to an LPN.
reinforcing the teaching
An LPN can perform ______care.
tracheostomy care
Can an RN delegate to an LPN to perform suctioning?
yes
Can an RN delegate to an LPN to put in a urinary catheter?
yes
Can an RN delegate to an AP to feed a client not on swallow precautions?
yes
Is an RN allowed to delegate to an AP to collect a urine sample?
yes
A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required naloxone (narcan) for depressed respirations. Is this an appropriate task for the AP?
no
An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first?
A. Call the client’s provider
B. Ask a staff member for assistance getting the client back in bed
C. Inspect the client for injuries
D. Ask the client why he got out of bed w/out assistance
C. Inspect the client for injuries
An RN on a med-surg unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN?
A. Obtain vitals for a client who is 2 hr postop following a cardiac cath
B. Administering a unit of PRBCs
C. Instructing a client in the performance of wound care
D. Developing a plan of care for a newly admitted client
A
A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client’s son asks the nurse what med is being given to the client. Which of the following is an appropriate response by the nurse?
A. “I am sorry, but that is information you will need to ask your mother or her doctor.”
B. “Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan) for anxiety.”
C. “You will need to ask the charge nurse for that info.”
D. “Don’t worry. We will give your mother all pertinent info before discharge.”
A.
A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the following describes a case management approach to care?
A. A nurse provides total care for several clients
B. Collaboration between disciplines creates a multidisciplinary care plan for each client.
C. The focus of care is on detecting disorders at an early stage.
D. The team leader assigns care for a group of clients
B
A nurse overhears a client talking with an attorney, reporting physical abuse, use of restraints & denial of meals. What action should the nurse take?
A. Report the conversation to the nurse manager to allow for follow-up investigation.
B. Question the client about the allegations to identify staff who were allegedly involved.
C. Ignore the conversation unless the client brings it to the attention of the nurse.
D. Recognize this as a privileged communication that cannot be discussed w/anyone.
A
A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select all that apply.
A. Discussing treatment options w/a client who was pancreatic cancer
B. Notifying the surgeon when a client signing a surgical consent form has questions about the procedure
C. Helping a client make a list of questions she would like to ask the provider
D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function
E. Carrying out end-of-life wishes outlined in the living will of an older adult
B, C, D, E
A nurse is assessing a client’s negligible progress in following a weight loss program. Which of the following is a likely reason the client was unable to achieve a short-term goal established during the planning phase of the nursing process?
A. The goals were realistic & formulated w/client input.
B. The underlying problem behind past weight gain was misidentified.
C. The implementation of the plan used flexibility in following the nursing actions
D. The nurse obtained objective & subjective data during the assessment.
B
A nurse has prepared an IM injection for a client who is preoperative, when another client suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is waiting to take the client to surgery. Which of the following is an appropriate action by the LPN?
A. Prepare a new syringe for the client who is preop
B. Give the prepared med to the client who is preop
C. Help the client requesting assistance so the nurse can give the prepared injection
D. Report this request to the charge nurse
C
A new charge nurse on a busy surgical unit notes a high degree of tension among the nursing staff. Which of the following should be the initial method used for resolving this issue?
A. Work w/the nurses to identify stressors
B. Hire additional staff to decrease the work load
C. Make relaxation tapes available to staff to help decrease stress
D. Reassess the situation after the nurses have become accustomed to the new charge nurse
A
A nurse on a long-term care unit finds that a client receiving dialysis was administered captopril (capoten), which was not prescribed for the client. In which order should the nurse take the actions listed?
___Complete an incident report.
___Contact the risk manager.
___Instruct the client to call for assistance when getting out of bed.
___Measure the client’s vital signs
___Notify the provider
- Measure the client’s vitals
- Instruct the client to call for assistance when getting out of bed
- Notify provider
- Complete an incident report
- Contact the risk manager
A nurse is caring for a group of clients on a med surg unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? Select all that apply.
A. Collecting a stool specimen
B. Providing instructions about using a spirometer
C. Measuring oral intake
D. Providing postmortem care
E. Changing a dressing
A, C, D
A nurse on a med surg unit is planning care of assigned clients. Which of the following clients should the nurse assess first?
A. A client who is newly admitted & is to have an indwelling urinary catheter inserted
B. A client who has kidney stones & reports flank pain 6 out of 10
C. A client diagnosed w/early-stage chronic kidney disease w/a serum creatinine level of 2.0 mg/dL
D. A client who has a cast newly applied on his forearm and reports tingling of his fingers
D
An RN working w/an LPN is planning client care assignments. Which of the following tasks should the nurse delegate to the LPN?
A. Performing tracheostomy suctioning for a stable client
B. Performing an admission assessment of a client who is preop
C. Initiating the referral of a client to hospice
D. Interpreting a client’s digoxin level
A
A client is prescribed morphine sulfate IM. Which of the following should the nurse recognize as a requirement for governing controlled substances?
A. Delegate med admin to a RN
B. Ask another nurse to observe disposal of unused med
C. Request another nurse to validate admin of the med
D. Observe the LPN admin the med
B
An older adult client who has early Alzheimer’s disease is living w/an adult child who is employed part-time but is committed to keeping her parent at home. Which of the following options is appropriate for the nurse to discuss w/the client & family at this time?
A. Hospice care
B. Adult day care
C. An assisted-living facility
D. Long-term care facility
B
A nurse is overheard telling other nurses that the unit manager gives preferential treatment to nurses on the night shift. Which of the following approaches by the unit manager reflects an assertive response to resolution of this conflict?
A. Understand that the vocal nurse is misinformed & take no action.
B. Assign the vocal staff nurse to work the night shift to allow direct experience w/the night shift.
C. Meet one-on-one w/the vocal staff nurse to discuss the concerns raised
D. Confront the staff nurse during the next unit meeting regarding her statement
C
A nurse is caring for a group of clients on a medical unit. Which of the following is the priority finding the nurse should report to the provider?
A. A client receiving metoclopramide (Reglan) reports diarrhea
B. A client receiving tamsulosin (Flomax) reports feeling dizzy
C. A client receiving cephalexin (Keflex) reports dyspnea
D. A client receiving erythromycin (E-Mycin) reports epigastric pain
C
A nurse is caring for a client who has recently been prescribed lithium carbonate (Eskalith). Which of the following is the priority assessment finding for this client?
A. Fine hand tremors
B. Weight gain of 2.7 kg (6 lb)
C. Report of nausea
D. Poor motor coordination
D
A nurse manager is reviewing the function of “Code of Ethics for Nurses with Interpretive Statements” during a staff meeting. The nurse manager recognizes that this document is:
A. legally binding
B. mandatory for the practice of nursing
C. a description of requirements for licensure
D. a guide for professional actions
D.
A nurse manager finds an increased incidence of health-care associated infections (HAIs) on a long term care unit. Which of the following is the priority action the nurse manager should take to address the problem?
A. Monitor the staff’s hand hygiene techniques
B. Hold a mandatory in-service about hand hygiene & infection rates
C. Require nurses to take an online course on HAIs
D. Conduct a chart review to gather data about clients who developed HAIs
D
A nurse manager is about to write a 2 month performance appraisal for a newly graduated nurse. Which of the following factors should the nurse manager take into consideration when planning a performance appraisal interview for this nurse?
A. The written appraisal & interview should sound friendly & be informal
B. No one except the nurse manager should have input regarding the nurses’s appraisal
C. A nursing administrator who does not know the nurse should conduct the interview to promote fairness
D. The nurse should have a copy of performance standards before the appraisal interview
D
A nurse working at a rehab facility attends an interdisciplinary team meeting for a client who has had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse expect to contribute to the plan of care? Select all that apply.
A. Nurse
B. Occupational therapist
C. Speech therapist
D. Physical therapist
E. Respiratory therapist
A, B, C, D
A nurse is writing a goal for a client’s reaction following the admin of a med. Which of the following phases of the nursing process should the nurse modify?
A. Planning
B. Evaluation
C. Analyzing
D. Assessment
A
The actual writing of an expected outcome is done in the planning phase of the nursing care plan.
A charge nurse on a med surg unit is assigning client care to an RN and an LPN. Which of the following tasks should the nurse assign to the RN? Select all that apply.
A. Performing colostomy care
B. Administering blood to a client
C. Developing a plan of care for a client
D. Calculating a TPN flow rate
E. Checking nasogastric tube patency
B, C, D
A nurse manager is providing info about the audit process to members of the nursing team. Which of the following statements should the nurse manager include? Select all that apply.
A. A structure audit evaluates the setting & resources available to provide care
B. An outcome audit evaluates 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, B, C, E
A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following will provide the most relevant info regarding the efficacy of the procedure?
A. Frequency w/which the procedure is performed
B. Client satisfaction w/performance of procedure
C. Incidence of complications r/t procedure
D. Accurate documentation of how the procedure was performed
C
A nurse manager has received a performance appraisal from the unit manager. Which of the following actions by the unit manager requires intervention?
A. The evaluation was conducted in the unit manager’s office
B. Data that was collected for the previous 12 months was presented
C. Verbal concerns provided by a staff member were incorporated into the data
D. The nurse was asked to review the performance appraisal & complete a self-evaluation
C
A nurse is preparing to transfer an older adult client who is 72 hr postop from a surgical procedure to a long term care facility. Which of the following should the nurse include in the transfer report? Select all that apply.
A. Type of anesthesia used
B. The client’s advance directives status
C. The client’s vital signs on day of admission
D. The client’s medical diagnosis
E. Need for special equipment
B, D, E
A nurse is participating in an interprofessional 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 also participate in planning care for this client? Select all that apply.
A. Physical therapist
B. Speech therapist
C. Occupational therapist
D. Psychologist
E. Vocational counselor
A, C, D, E
A nurse manager is working with a committee of nurses whose task is to update the policies for new employee orientation. The nurse manager directs the team to collect as much data as possible & recommend several options. Which of the following decision-making styles is being demonstrated by the nurse manager?
A. Decisive
B. Flexible
C. Hierarchical
D. Integrative
D.
A nurse who has just assumed the role of unit manager is examining her skills in interprofressional collaboration. Which of the following actions support interprofessional collaboration? Select all that apply.
A. Use aggressive communication when addressing the team
B. Recognize the knowledge & skills of each member of the team
C. Ensure that a nurse is assigned to serve as the group facilitator for all interdisciplinary meetings
D. Encourage the client & family to participate in the team meeting
E. Support team member requests for referral
B, D, E
A nurse is caring for a client who is being prepared for surgery. The client hands the nurse info about advance directives & states, “Here, I don’t need this. I am too young to worry about life-sustaining measures & what I want done for me.” Which of the following actions should the nurse take?
A. Return the papers to the admitting dept w/a note stating that the client doesn’t wish to address the issue at this time.
B. Explain to the client that you never know what can happen during surgery & that he should fill the paper’s out “just in case.”
C. Contact a client representative to talk w/the client & offer additional info about the purpose of advance directives
D. Inform the client that the surgery cannot be conducted unless he completes his advance directives forms
C
A nurse is serving as a preceptor to a newly licensed nurse & 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 catheterization
B. Discussing treatment options for a terminal diagnosis
C. Informing members of the health care team that a client has DNR 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 nurse’s recommendations
A, C, D
A nurse manager is providing info to the nurses on the unit about ensuring client rights. Which of the following outlines the rights of individuals in health care settings?
A. American Nurses Association Code of Ethics
B. HIPAA
C. Patient Self-Determination Act
D. Patient Care Partnership
C
A nurse is reviewing a client’s health care record & discovers that the client’s DNR order has expired. The client’s condition is not stable. Which of the following actions should the nurse take?
A. Assume that the client does not want be resuscitated, & take no action if she experiences cardiac arrest
B. Write a note on the front of the provider order sheet asking that the DNR order be reordered
C. Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest
D. Call the provider to determine whether the order should be immediately reinstated
D
A home health nurse is assessing the safety of a client’s home. Which of the following factors may increase the client’s risk for falls? Select all that apply.
A. History of a previous fall
B. Reduced vision
C. Impaired memory
D. Takes rosuvastatin (Crestor)
E. Wears house slippers
F. Kyphosis
A, B, C, E, F
A client is brought back to the unit after a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocate the new hip joint, & repeatedly attempts to get out of bed. Which of the following actions should the nurse take? Select all that apply.
A. Apply arm & leg restraints immediately
B. Get an order from the provider
C. Have a family member sign the consent for restraints
D. Use a square knot to secure the restraints to the bed frame
E. Ensure that only one finger can be inserted between the restraint and the client
A, B, C
A nurse is observing a newly licensed nurse & an AP pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates a need for further education?
A. The nurse spreads his legs apart
B. The nurse uses his body weight to counter the client’s weight
C. The nurse’s feet are facing inward, toward the center of the bed
D. The nurse uses the muscles in his arms to lift the client off the bed using the drawsheet
C
An AP reports that a client’s finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client’s morning finger-stick blood glucose was 285 mg/dL. The client is asymptomatic for hypoglycemia, & his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?
A. Recalibrate the glucometer, & recheck the client’s blood glucose
B. Have the lab draw a stat serum glucose
C. Inform the AP to give the client 120 mL of orange juice
D. Administer insulin as prescribed
A
A nurse discovers that a client was administered an antihypertensive med in error. Number the following actions in the appropriate sequence that the nurse should follow.
___A. Call the client’s provider
___B. Monitor the client’s vitals
___C. Notify the risk manager
___D. Complete an incident report
___E. Instruct the client to remain in bed until further notice
- B
- E
- A
- D
- C
A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? Select all that apply.
A. A description of the incident should be documented in the client’s health care record
B. Incident reports should not be shared w/the client
C. Incident reports include a description of the incident & actions taken
D. A copy of the incident report should be placed in the client’s health care record
E. The risk management dept. investigates the incident
A, B, C, E
Managing Client Care: Appropriate Assignment During Orientation
New RNs should be assigned a patient that they are competent caring for, and only after their skills have been observed and approved by an experienced RN.
Airway Management: Discharge planning for a Client Who Has a Tracheostomy
Always have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times.
Professional Responsibilities: Responding to a Visitor’s Question About Status of a Client
Information cannot be shared with unauthorized individuals, including family members, unless they provide the code.
Professional Responsibilities: Teaching About Confidentiality
Client medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions.
Preoperative Nursing Care: Securing Client Belongings
Give all pt belongings to family member to safely stored.
Managing Client Care: Prioritizing Client Care
Systemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don’t assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action.
Professional Responsibilities: Adhering to Ethical Principles
Justice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness).
Professional Responsibilities: Obtaining Informed Consent in an Emergency
Informed consent is not needed if the pt is unconscious and surgery is immediately required to save their life.
Information Technology: Receiving a Telephone prescription
First, write down the prescription. Next, repeat the prescription back to the provider. Document phone conversation in client chart.
Professional Responsibilities: Identifying a Tort
A wrongful act or an infringement of a right
Managing Client Care: Performance Improvement Process
Standards are made available to employees by way of polices and procedures. Quality issues are identified by staff, management, or risk management department. an inter professional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined.
Maintaining a Safe Environment: Assessing a Client’s Home for Safety Hazards
Remove items that could cause client to trip. Place electrical cords against the wall. Make sure steps and sidewalks are in good repair. Place grab bars near the toilet and the tub. Use nonskid mat in the tub or shower. Ensure lighting is adequate.
Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
Inflammation means that the body’s immune system is working to heal the wound.
Coordinating Client Care: Need for Variance Report
A variance report compares the planned budget and the actual financial outcome.
Facility Protocols: Caring for a Client Who Has Been Exposed to Anthrax
Treat with antibiotics.
Managing Client Care: Appropriate Assignment During Orientation
New RNs should be assigned a patient that they are competent caring for, and only after their skills have been observed and approved by an experienced RN.
Airway Management: Discharge planning for a Client Who Has a Tracheostomy
Always have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times.
Professional Responsibilities: Responding to a Visitor’s Question About Status of a Client
Information cannot be shared with unauthorized individuals, including family members, unless they provide the code.
Professional Responsibilities: Teaching About Confidentiality
Client medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions.
Preoperative Nursing Care: Securing Client Belongings
Give all pt belongings to family member to safely stored.
Managing Client Care: Prioritizing Client Care
Systemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don’t assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action.
Professional Responsibilities: Adhering to Ethical Principles
Justice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness).
Professional Responsibilities: Obtaining Informed Consent in an Emergency
Informed consent is not needed if the pt is unconscious and surgery is immediately required to save their life.
Information Technology: Receiving a Telephone prescription
First, write down the prescription. Next, repeat the prescription back to the provider. Document phone conversation in client chart.
Professional Responsibilities: Identifying a Tort
A wrongful act or an infringement of a right
Managing Client Care: Performance Improvement Process
Standards are made available to employees by way of polices and procedures. Quality issues are identified by staff, management, or risk management department. an inter professional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined.
Maintaining a Safe Environment: Assessing a Client’s Home for Safety Hazards
Remove items that could cause client to trip. Place electrical cords against the wall. Make sure steps and sidewalks are in good repair. Place grab bars near the toilet and the tub. Use nonskid mat in the tub or shower. Ensure lighting is adequate.
Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
Inflammation means that the body’s immune system is working to heal the wound.
Coordinating Client Care: Need for Variance Report
A variance report compares the planned budget and the actual financial outcome.
Facility Protocols: Caring for a Client Who Has Been Exposed to Anthrax
Treat with antibiotics.
An RN has to teach the client initially but can delegate ________to an LPN.
reinforcing the teaching
An LPN can perform ______care.
tracheostomy care
Can an RN delegate to an LPN to perform suctioning?
yes
Can an RN delegate to an LPN to put in a urinary catheter?
yes
Can an RN delegate to an AP to feed a client not on swallow precautions?
yes
Is an RN allowed to delegate to an AP to collect a urine sample?
yes
A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required naloxone (narcan) for depressed respirations. Is this an appropriate task for the AP?
no
An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first?
A. Call the client’s provider
B. Ask a staff member for assistance getting the client back in bed
C. Inspect the client for injuries
D. Ask the client why he got out of bed w/out assistance
C. Inspect the client for injuries
An RN on a med-surg unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN?
A. Obtain vitals for a client who is 2 hr postop following a cardiac cath
B. Administering a unit of PRBCs
C. Instructing a client in the performance of wound care
D. Developing a plan of care for a newly admitted client
A
A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client’s son asks the nurse what med is being given to the client. Which of the following is an appropriate response by the nurse?
A. “I am sorry, but that is information you will need to ask your mother or her doctor.”
B. “Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan) for anxiety.”
C. “You will need to ask the charge nurse for that info.”
D. “Don’t worry. We will give your mother all pertinent info before discharge.”
A.
A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the following describes a case management approach to care?
A. A nurse provides total care for several clients
B. Collaboration between disciplines creates a multidisciplinary care plan for each client.
C. The focus of care is on detecting disorders at an early stage.
D. The team leader assigns care for a group of clients
B
A nurse overhears a client talking with an attorney, reporting physical abuse, use of restraints & denial of meals. What action should the nurse take?
A. Report the conversation to the nurse manager to allow for follow-up investigation.
B. Question the client about the allegations to identify staff who were allegedly involved.
C. Ignore the conversation unless the client brings it to the attention of the nurse.
D. Recognize this as a privileged communication that cannot be discussed w/anyone.
A
A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select all that apply.
A. Discussing treatment options w/a client who was pancreatic cancer
B. Notifying the surgeon when a client signing a surgical consent form has questions about the procedure
C. Helping a client make a list of questions she would like to ask the provider
D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function
E. Carrying out end-of-life wishes outlined in the living will of an older adult
B, C, D, E
A nurse is assessing a client’s negligible progress in following a weight loss program. Which of the following is a likely reason the client was unable to achieve a short-term goal established during the planning phase of the nursing process?
A. The goals were realistic & formulated w/client input.
B. The underlying problem behind past weight gain was misidentified.
C. The implementation of the plan used flexibility in following the nursing actions
D. The nurse obtained objective & subjective data during the assessment.
B
A nurse has prepared an IM injection for a client who is preoperative, when another client suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is waiting to take the client to surgery. Which of the following is an appropriate action by the LPN?
A. Prepare a new syringe for the client who is preop
B. Give the prepared med to the client who is preop
C. Help the client requesting assistance so the nurse can give the prepared injection
D. Report this request to the charge nurse
C
A new charge nurse on a busy surgical unit notes a high degree of tension among the nursing staff. Which of the following should be the initial method used for resolving this issue?
A. Work w/the nurses to identify stressors
B. Hire additional staff to decrease the work load
C. Make relaxation tapes available to staff to help decrease stress
D. Reassess the situation after the nurses have become accustomed to the new charge nurse
A
A nurse on a long-term care unit finds that a client receiving dialysis was administered captopril (capoten), which was not prescribed for the client. In which order should the nurse take the actions listed?
___Complete an incident report.
___Contact the risk manager.
___Instruct the client to call for assistance when getting out of bed.
___Measure the client’s vital signs
___Notify the provider
- Measure the client’s vitals
- Instruct the client to call for assistance when getting out of bed
- Notify provider
- Complete an incident report
- Contact the risk manager
A nurse is caring for a group of clients on a med surg unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? Select all that apply.
A. Collecting a stool specimen
B. Providing instructions about using a spirometer
C. Measuring oral intake
D. Providing postmortem care
E. Changing a dressing
A, C, D
A nurse on a med surg unit is planning care of assigned clients. Which of the following clients should the nurse assess first?
A. A client who is newly admitted & is to have an indwelling urinary catheter inserted
B. A client who has kidney stones & reports flank pain 6 out of 10
C. A client diagnosed w/early-stage chronic kidney disease w/a serum creatinine level of 2.0 mg/dL
D. A client who has a cast newly applied on his forearm and reports tingling of his fingers
D
An RN working w/an LPN is planning client care assignments. Which of the following tasks should the nurse delegate to the LPN?
A. Performing tracheostomy suctioning for a stable client
B. Performing an admission assessment of a client who is preop
C. Initiating the referral of a client to hospice
D. Interpreting a client’s digoxin level
A
A client is prescribed morphine sulfate IM. Which of the following should the nurse recognize as a requirement for governing controlled substances?
A. Delegate med admin to a RN
B. Ask another nurse to observe disposal of unused med
C. Request another nurse to validate admin of the med
D. Observe the LPN admin the med
B
An older adult client who has early Alzheimer’s disease is living w/an adult child who is employed part-time but is committed to keeping her parent at home. Which of the following options is appropriate for the nurse to discuss w/the client & family at this time?
A. Hospice care
B. Adult day care
C. An assisted-living facility
D. Long-term care facility
B
A nurse is overheard telling other nurses that the unit manager gives preferential treatment to nurses on the night shift. Which of the following approaches by the unit manager reflects an assertive response to resolution of this conflict?
A. Understand that the vocal nurse is misinformed & take no action.
B. Assign the vocal staff nurse to work the night shift to allow direct experience w/the night shift.
C. Meet one-on-one w/the vocal staff nurse to discuss the concerns raised
D. Confront the staff nurse during the next unit meeting regarding her statement
C
A nurse is caring for a group of clients on a medical unit. Which of the following is the priority finding the nurse should report to the provider?
A. A client receiving metoclopramide (Reglan) reports diarrhea
B. A client receiving tamsulosin (Flomax) reports feeling dizzy
C. A client receiving cephalexin (Keflex) reports dyspnea
D. A client receiving erythromycin (E-Mycin) reports epigastric pain
C
A nurse is caring for a client who has recently been prescribed lithium carbonate (Eskalith). Which of the following is the priority assessment finding for this client?
A. Fine hand tremors
B. Weight gain of 2.7 kg (6 lb)
C. Report of nausea
D. Poor motor coordination
D
A nurse manager is reviewing the function of “Code of Ethics for Nurses with Interpretive Statements” during a staff meeting. The nurse manager recognizes that this document is:
A. legally binding
B. mandatory for the practice of nursing
C. a description of requirements for licensure
D. a guide for professional actions
D.
A nurse manager finds an increased incidence of health-care associated infections (HAIs) on a long term care unit. Which of the following is the priority action the nurse manager should take to address the problem?
A. Monitor the staff’s hand hygiene techniques
B. Hold a mandatory in-service about hand hygiene & infection rates
C. Require nurses to take an online course on HAIs
D. Conduct a chart review to gather data about clients who developed HAIs
D
A nurse manager is about to write a 2 month performance appraisal for a newly graduated nurse. Which of the following factors should the nurse manager take into consideration when planning a performance appraisal interview for this nurse?
A. The written appraisal & interview should sound friendly & be informal
B. No one except the nurse manager should have input regarding the nurses’s appraisal
C. A nursing administrator who does not know the nurse should conduct the interview to promote fairness
D. The nurse should have a copy of performance standards before the appraisal interview
D
A nurse working at a rehab facility attends an interdisciplinary team meeting for a client who has had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse expect to contribute to the plan of care? Select all that apply.
A. Nurse
B. Occupational therapist
C. Speech therapist
D. Physical therapist
E. Respiratory therapist
A, B, C, D
A nurse is writing a goal for a client’s reaction following the admin of a med. Which of the following phases of the nursing process should the nurse modify?
A. Planning
B. Evaluation
C. Analyzing
D. Assessment
A
The actual writing of an expected outcome is done in the planning phase of the nursing care plan.
A charge nurse on a med surg unit is assigning client care to an RN and an LPN. Which of the following tasks should the nurse assign to the RN? Select all that apply.
A. Performing colostomy care
B. Administering blood to a client
C. Developing a plan of care for a client
D. Calculating a TPN flow rate
E. Checking nasogastric tube patency
B, C, D
A nurse manager is providing info about the audit process to members of the nursing team. Which of the following statements should the nurse manager include? Select all that apply.
A. A structure audit evaluates the setting & resources available to provide care
B. An outcome audit evaluates 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, B, C, E
A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following will provide the most relevant info regarding the efficacy of the procedure?
A. Frequency w/which the procedure is performed
B. Client satisfaction w/performance of procedure
C. Incidence of complications r/t procedure
D. Accurate documentation of how the procedure was performed
C
A nurse manager has received a performance appraisal from the unit manager. Which of the following actions by the unit manager requires intervention?
A. The evaluation was conducted in the unit manager’s office
B. Data that was collected for the previous 12 months was presented
C. Verbal concerns provided by a staff member were incorporated into the data
D. The nurse was asked to review the performance appraisal & complete a self-evaluation
C
A nurse is preparing to transfer an older adult client who is 72 hr postop from a surgical procedure to a long term care facility. Which of the following should the nurse include in the transfer report? Select all that apply.
A. Type of anesthesia used
B. The client’s advance directives status
C. The client’s vital signs on day of admission
D. The client’s medical diagnosis
E. Need for special equipment
B, D, E
A nurse is participating in an interprofessional 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 also participate in planning care for this client? Select all that apply.
A. Physical therapist
B. Speech therapist
C. Occupational therapist
D. Psychologist
E. Vocational counselor
A, C, D, E
A nurse manager is working with a committee of nurses whose task is to update the policies for new employee orientation. The nurse manager directs the team to collect as much data as possible & recommend several options. Which of the following decision-making styles is being demonstrated by the nurse manager?
A. Decisive
B. Flexible
C. Hierarchical
D. Integrative
D.
A nurse who has just assumed the role of unit manager is examining her skills in interprofressional collaboration. Which of the following actions support interprofessional collaboration? Select all that apply.
A. Use aggressive communication when addressing the team
B. Recognize the knowledge & skills of each member of the team
C. Ensure that a nurse is assigned to serve as the group facilitator for all interdisciplinary meetings
D. Encourage the client & family to participate in the team meeting
E. Support team member requests for referral
B, D, E
A nurse is caring for a client who is being prepared for surgery. The client hands the nurse info about advance directives & states, “Here, I don’t need this. I am too young to worry about life-sustaining measures & what I want done for me.” Which of the following actions should the nurse take?
A. Return the papers to the admitting dept w/a note stating that the client doesn’t wish to address the issue at this time.
B. Explain to the client that you never know what can happen during surgery & that he should fill the paper’s out “just in case.”
C. Contact a client representative to talk w/the client & offer additional info about the purpose of advance directives
D. Inform the client that the surgery cannot be conducted unless he completes his advance directives forms
C
A nurse is serving as a preceptor to a newly licensed nurse & 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 catheterization
B. Discussing treatment options for a terminal diagnosis
C. Informing members of the health care team that a client has DNR 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 nurse’s recommendations
A, C, D
A nurse manager is providing info to the nurses on the unit about ensuring client rights. Which of the following outlines the rights of individuals in health care settings?
A. American Nurses Association Code of Ethics
B. HIPAA
C. Patient Self-Determination Act
D. Patient Care Partnership
D
A nurse is reviewing a client’s health care record & discovers that the client’s DNR order has expired. The client’s condition is not stable. Which of the following actions should the nurse take?
A. Assume that the client does not want be resuscitated, & take no action if she experiences cardiac arrest
B. Write a note on the front of the provider order sheet asking that the DNR order be reordered
C. Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest
D. Call the provider to determine whether the order should be immediately reinstated
D
A home health nurse is assessing the safety of a client’s home. Which of the following factors may increase the client’s risk for falls? Select all that apply.
A. History of a previous fall
B. Reduced vision
C. Impaired memory
D. Takes rosuvastatin (Crestor)
E. Wears house slippers
F. Kyphosis
A, B, C, E, F
A client is brought back to the unit after a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocate the new hip joint, & repeatedly attempts to get out of bed. Which of the following actions should the nurse take? Select all that apply.
A. Apply arm & leg restraints immediately
B. Get an order from the provider
C. Have a family member sign the consent for restraints
D. Use a square knot to secure the restraints to the bed frame
E. Ensure that only one finger can be inserted between the restraint and the client
A, B, C
A nurse is observing a newly licensed nurse & an AP pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates a need for further education?
A. The nurse spreads his legs apart
B. The nurse uses his body weight to counter the client’s weight
C. The nurse’s feet are facing inward, toward the center of the bed
D. The nurse uses the muscles in his arms to lift the client off the bed using the drawsheet
C
An AP reports that a client’s finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client’s morning finger-stick blood glucose was 285 mg/dL. The client is asymptomatic for hypoglycemia, & his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?
A. Recalibrate the glucometer, & recheck the client’s blood glucose
B. Have the lab draw a stat serum glucose
C. Inform the AP to give the client 120 mL of orange juice
D. Administer insulin as prescribed
A
A nurse discovers that a client was administered an antihypertensive med in error. Number the following actions in the appropriate sequence that the nurse should follow.
___A. Call the client’s provider
___B. Monitor the client’s vitals
___C. Notify the risk manager
___D. Complete an incident report
___E. Instruct the client to remain in bed until further notice
- B
- E
- A
- D
- C
A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? Select all that apply.
A. A description of the incident should be documented in the client’s health care record
B. Incident reports should not be shared w/the client
C. Incident reports include a description of the incident & actions taken
D. A copy of the incident report should be placed in the client’s health care record
E. The risk management dept. investigates the incident
A, B, C, E
Managing Client Care: Appropriate Assignment During Orientation
New RNs should be assigned a patient that they are competent caring for, and only after their skills have been observed and approved by an experienced RN.
Airway Management: Discharge planning for a Client Who Has a Tracheostomy
Always have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times.
Professional Responsibilities: Responding to a Visitor’s Question About Status of a Client
Information cannot be shared with unauthorized individuals, including family members, unless they provide the code.
Professional Responsibilities: Teaching About Confidentiality
Client medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions.
Preoperative Nursing Care: Securing Client Belongings
Give all pt belongings to family member to safely stored.
Managing Client Care: Prioritizing Client Care
Systemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don’t assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action.
Professional Responsibilities: Adhering to Ethical Principles
Justice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness).
Professional Responsibilities: Obtaining Informed Consent in an Emergency
Informed consent is not needed if the pt is unconscious and surgery is immediately required to save their life.
Information Technology: Receiving a Telephone prescription
First, write down the prescription. Next, repeat the prescription back to the provider. Document phone conversation in client chart.
Professional Responsibilities: Identifying a Tort
A wrongful act or an infringement of a right
Managing Client Care: Performance Improvement Process
Standards are made available to employees by way of polices and procedures. Quality issues are identified by staff, management, or risk management department. an inter professional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined.
Maintaining a Safe Environment: Assessing a Client’s Home for Safety Hazards
Remove items that could cause client to trip. Place electrical cords against the wall. Make sure steps and sidewalks are in good repair. Place grab bars near the toilet and the tub. Use nonskid mat in the tub or shower. Ensure lighting is adequate.
Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
Inflammation means that the body’s immune system is working to heal the wound.
Coordinating Client Care: Need for Variance Report
A variance report compares the planned budget and the actual financial outcome.
Facility Protocols: Caring for a Client Who Has Been Exposed to Anthrax
Treat with antibiotics.
Managing Client Care: Appropriate Assignment During Orientation
New RNs should be assigned a patient that they are competent caring for, and only after their skills have been observed and approved by an experienced RN.
Airway Management: Discharge planning for a Client Who Has a Tracheostomy
Always have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times.
Professional Responsibilities: Responding to a Visitor’s Question About Status of a Client
Information cannot be shared with unauthorized individuals, including family members, unless they provide the code.
Professional Responsibilities: Teaching About Confidentiality
Client medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions.
Preoperative Nursing Care: Securing Client Belongings
Give all pt belongings to family member to safely stored.
Managing Client Care: Prioritizing Client Care
Systemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don’t assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action.
Professional Responsibilities: Adhering to Ethical Principles
Justice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness).
Professional Responsibilities: Obtaining Informed Consent in an Emergency
Informed consent is not needed if the pt is unconscious and surgery is immediately required to save their life.
Information Technology: Receiving a Telephone prescription
First, write down the prescription. Next, repeat the prescription back to the provider. Document phone conversation in client chart.
Professional Responsibilities: Identifying a Tort
A wrongful act or an infringement of a right
Managing Client Care: Performance Improvement Process
Standards are made available to employees by way of polices and procedures. Quality issues are identified by staff, management, or risk management department. an inter professional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined.
Maintaining a Safe Environment: Assessing a Client’s Home for Safety Hazards
Remove items that could cause client to trip. Place electrical cords against the wall. Make sure steps and sidewalks are in good repair. Place grab bars near the toilet and the tub. Use nonskid mat in the tub or shower. Ensure lighting is adequate.
Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
Inflammation means that the body’s immune system is working to heal the wound.
Coordinating Client Care: Need for Variance Report
A variance report compares the planned budget and the actual financial outcome.
Facility Protocols: Caring for a Client Who Has Been Exposed to Anthrax
Treat with antibiotics.
A nurse is caring for a client who has a tumor, the provider recommends surgery. the client refuses but clients partner wants it. Which of the following determines if the surgery will be done
The clients partner is the durable power of attorney
Client understands risk and refusing
Clients refusal
Ethics commity
client understands risk and refusing
New diagnosis of chlamydia
Report to local health department
Initiate contact precaution
Use condoms
Apply antiviral
report to local health department
A nurse is caring for a client who has cancer, the client’s adult child asks the nurse for info about treatment plan. How should nurse respond?
Speak to mother
Provider will speak with you
I cannot provide without consent
What would you like to know about it?
i cannot provide without consent
A nurse is assessing an older adult client who was brought to the ER by his adult son, reports he fell at home. Nurse suspects abuse, action to take?
Treat / discharge
File incident report
Ask client about injuries while son is present
Ask son to go to waiting area
ask son to go to waiting area
A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct to apply to a client who has full thickness burns over side of body
a. Red
b. Yellow
c. Green
d. Black
black
A nurse on a med surg unit is caring for a client who asks about advance directives and wants to appoint a health care proxy. Which of the following responses should the nurse make?
Choose a family member
Attorney
Decisions when you are unable to do so
Appoint before undergoing procedure
decisions when you are unable to do so
A hospice nurse is caring for a client who has a terminal illness. Reports severe pain, prescribed meds, difficult to arouse. Nurse should
a. Continue opioid
Contact provider
Administer benzo Without opioid
Continue the medication dosages
continue the medication dosages
A nurse is orienting a newly licensed nurse about confidentiality. Which indicates an understanding?
Use another’s password as long as I log off after
Discard personal info in trash before leaving
Post clients signs in room
Encrypt when sending emails
encrypt when sending emails
A nurse is delegating care for a group of clients. Which of the following should be assigned to an LVN?
Scheduled endoscopy, enema
DM requires teaching
Client who has MI, transferring to unit from CCU
New client with sickle cell
scheduled enema
A nurse on a med surg unit is caring for 4 clients. Highest priority?
MRSA
Absent pedal pulse in the right foot
Post op, able to void
Pancreatic cancer new dx
absent pedal pulse in the right foot
manager, cna incorrectly transferring to bedside commode, actions for nurse
refer to procedure manual
Help AP assist client with transfer
instruct to request assist when unsure with a task
help ap assist client with transfer
Nurse in ER admits clients exposed to anthrax
a. Prepare to administer abx to client
b. Antiviral
prepare to administer antibiotics to client
A nurse is caring for a client who is unconscious, partner is health care surrogate, partner
wants to dc feeding tube, another family wants to continue tx
Contact provider
Speak with ethics committee
Nursing supervisor
speak with ethiccs committee
a nurse is preparing to discontinue client with end stage heart failure, partner can no longer care
a. ask another family member to assist
ask provider to delay dc
contact case manager
recommend long term facility
contact case manager
A nurse is providing COS report for oncoming nurse. Nurse should include
Local banks
Vital signs as prescribed
Radiology for xray
Clients partner came 2 hours ago
Clients partner came 2 hours ago
A nurse in er is preparing for client who arrived via ambulance, disoriented, cardiac arrythmia, action for nurse
High risk manager
Clients next of kin
Client sign
Proceed with procedure without consent
proceed with procedure with consent
A nurse is preparing to dc client who requires home oxygen, company has not delivered tank
Notify provider about delay
Contact social services
Instruct family to contact insurance provider
Send one home from facility
contact social services
A nurse from med surg caring for group of clients, delegate to LPN?
Urine specimen from older adult client
Wound debridement to PT
Postmortem care
Reinforce dietary teaching for heart disease
urine specimen from older adult client
Manager leading discussion on ethical dilemmas, example
Minor burn from coffee
Operation on wrong side of body
Parent wants teen to receive radiation against will
Rn witnesses another rn give incorrect med
parents wants teen to receive radiation against will
nurse develops dc plan for postop and needs wheel chair. refferral?
home health
caring for client who asks about prevalence of disease, rn obtains info by
evidence based journal
rn completed electronic record, ap finished vitals
log out so ap can log in
nurse is preparing teaching for a different language, intervention
interpreter
a nurse is preparing to transfer to facility, include what info for cos report
the time the client received last pain med dose
nurse on inpatient care unit work to reduce costs, cost containment plan
use clean gloves rather than sterile gloves for colostomy care
incident report for medication error
include time med occurred
preparing client for elective mastectomoy, want to wear wedding band
place with clothing
med surg unit, evaluating ap infection control actions, correct use of precautions
removes gloves before leaving room mrsa
education program for staff regarding new iv pump, sequence of actions
schedule different sessions
client rights inservice
responsible for informing client about tx options
receiving rx from provider for client with increased pain, add to medical record
iv prn for pain
rn caring for client who reports acute pain but refuses im medication, distracts client and quickly administers med, illustrates which of the following
battery
dc teaching to parents of toddler with asthma, unable to afford nebulizer for client, recommend
social worker
newly licensed nurse on isolation precautions, understanding
ambulatory client wear mask when outside
charge nurse on ob unit, client for rn floating from med surg
primigravida, 1 day post op c section
er nurse performing triage, priority
soot markings around nasal after house fire
tag as emergent
deep partial thickness burn on lower extremities
comparing rate of med errors on unit, quality improvement methods
benchmarking improvement
charge making rounds, ap applied restraints without prescription
remove restraints from wrists
er priority patient
sob
active bleeding
left should pain
transcutaneous electrical nerve stimulation, nurse should contact who for assistance
physical therapy
development of disaster management plan for hospital. highest priority available for bioterrorism event
supply of ppe
to resolve conflict between staff when changing policy, manager implements changes regardless of feelings of changes, strategy that the nurse manager is using
competing
new licensed nurse droplet precautions understanding
surg mask within 3 feet
charge witness ap failing protocol when discarding contaminated linens, action to take
discuss with ap
rn supervising ap feeding client with dysphagia, nurse is correct technique
instruct client to place chin to rest when swallowing
manager receives report, which requires intervention first
3 staff members call out
nurse in ambulatory care setting, orienting newly licensed nurse, preparing to return a call to a client, explain objective
assessing clients needs
assessing client who had meningitis, tell provider immediately
decreased loc
preparing client for surgery, client signed consent but is not concerned about the pain
i understand and its not too late to change
caring for client with anorexia, disciplinary teams for consultation sata
nutritional therapist
mental health
case manager
assessing client post op following left leg below the knee amputation, statement showing need for referral for occupational theapist
taking care of a toddler at home
nurse is caring for client who wanders halls, action nurse to take
administer sedative
preparing delegation for bathing end stage lung cancer
data collected specific needs related to turning
nurse in a long term care facility fall prevention includes
institute rounds q2 hours to offer toileting
nurse enters hallway and sees visitor looking at client medical record info
close tab
teaching new nurse about confidentiality, nurse should include which of the following that represents violation of confidentiality
providing copy of client’s medical record to paramedic
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?
d. 39 has negative contraction stress test
nurse working on quality improvement team that is assessing an increase in client falls at facility, nurse should include as quality improvement
id those at risk for falls
med surg unit caring for 4 clients, schedule interdisciplinary conference for the following
fluid risk
new nurse has trouble focusing and difficulty completing care for assigned clients
take time to plan at beginning of shift
case manager preparing dc for client with coronary artery bypass surgery
limited social support
nurse enters client room for witness of signed consent
inform provider that client needs additional clarification
charge notices 2 staff aren’t taking meal breaks, action to take
determine reasons the nurses are not taking scheduled breaks
client reports ap positioned him with excessive force
contact nurse manager
client with type 1 dm, client wants to go home
sign an ama
charge making staff assignments on med surg unit, delegate to ap
measuring 02
er nurse assessing client unconscious following mv crash, client requires immediate surgery, action to take
transport to operating room without verifying informed consent
4 clients, assess first
post op
- A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system?
A. Identify nurses who accept the change to help influence other staff nurses
B. Provide a brief overview of the new scheduling system immediately before
it implementation
C. Introduce the new scheduling system by describing how it will save the institution money
D. Offer to reassign staff who do not support the change to another unit
B. Provide a brief overview of the new scheduling system immediately before
it implementation OR A. Identify nurses who accept the change to help influence other staff nurses
- A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2hr after implementation of the care pathway
B. A blood culture was obtained after antibiotic therapy has been initiated
C. The route of antibiotic therapy on the care pathway was changed from IV to PO
D. An allergy to penicillin required an alternative antibiotic to be prescribed
A. Antibiotic therapy was initiated 2hr after implementation of the care pathway
- A nurse should recognize that an incident report is required when
A. A client refuses to attend physical therapy
B. A visitor pinches his finger in the client‟s bed frame
C. A client throws a box of tissues at a nurse
D. A nurse gives a med 30 min late
A. A client refuses to attend physical therapy
- Client satisfactory surveys from a med-surg unit indicate the pain is not being adequately relieved during the first 12 hr post-opt. The unit manager decides to identify post-opt pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery?
A. Prospective chart audit
B. Retrospective chart audit
C. Post-operative care policy
D. Pain assessment policy
D. Pain assessment policy - A nurse precepting a newly licenced nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
A. “Did you secure the restraints to the side rails of the bed?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
C. “Did you tie the restraints using double knot?”
D. “Are you removing the client‟s restraints every 4 hr?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
- A nurse is caring for an older adult client who has stage III pressure ulcer. The nurse request a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant?
A. Arrange the consultation for time when the nurse is caring for the client is able to be present for consultation
B. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
C. Request the consultation after several wound care treatment tried
D. Arrange for the wound care nurse specialist to see the client daily to provide
the recommended treatment
A. Arrange the consultation for time when the nurse is caring for the client is able to be present for consultation
- A client is admitted with TB and placed in a negative pressure room. Which of the following actions is appropriate?
A. Notify the local health department of the admission
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests
D. Determine who had contact with the client in the last 48 hr
D. Determine who had contact with the client in the last 48 hr
(maybe wrong)
POSSIBLY: A. Notify the local health department of the admission
- A nurse is caring for a client who is unconscious and whose partner is healthcare proxy. The partner has spoken with the provider and wishes to discontinue the client‟s feeding tube. The provider states the nurse, “I will not discontinue the client‟s treatment. His partner has no right to make decisions regarding the client‟s care. “Which of the following responses by the nurse is appropriate?
A. You should consider speaking with the facility’s ethics committee before making your decision
B. You have the right to make a decision, even if the partner is the client‟s health care proxy
C. The client has designated his partner as a health care proxy in his advance
directives.
D. We‟ll need to have the nursing supervisor review the client‟s advance directives
C. The client has designated his partner as a health care proxy in his advance
directives.
- A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following info is most important for the nurse to report at shift change?
A. Glasglow Coma scale score
B. Most recent blood glucose reading C. Lab test scheduled for next shift
D. Reddened area on the coccyx
A. Glasglow Coma scale score
- A nurse is assigned the following four clients for the current shift. Which of the following should the nurse assess first?
A. A client who has a hip fracture and is in Buck‟s traction
B. A client who has aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot
D. A client who has a C diff infection and needs a stool specimen
collected
D. A client who has a C diff infection and needs a stool specimen
collected
- A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take?
A. Notify the nursing supervisor about the issues
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
A. Notify the nursing supervisor about the issues
- The mother of a client with breast cancer states, it’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments. Which of the following actions is appropriate for client advocacy?
A. The nurse investigates potential resources to help the client purchase wig
B. The nurse explains to the mother that most clients with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother‟s concerns.
D. The nurse suggests counseling for the client‟s body image issues
A. The nurse investigates potential resources to help the client purchase wig
- Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is post-opt
B. A bed sheet from a client with bacterial pneumonia
C. A perineal pad from a client who is 24-hr post-vaginal delivery
D. An empty IV bag removed from a client who has HIV
D. An empty IV bag removed from a client who has HIV
- A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don‟tget
better, I‟m going to quit. “Which of the following responses appropriate?
A. “So you are upset about all the changes on the Unit”
B. “I think you have a right to be upset, I am tired of the changes too”
C. “Just stick with it a little longer. Things will get better soon
D. ” You should file complaints with hospital administrator
A. “So you are upset about all the changes on the Unit”
- According to the HIPAA regulations, which of the following is a violation of client confidentiality?
A. Telephone the pharmacy with a prescription for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client‟s disposition to the referring provider
D. Informing housekeeping staff that the client is in dialysis unit
D. Informing housekeeping staff that the client is in dialysis unit
- A Nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintaining sterile technique? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile field
A. Open the sterile pack by first unfolding the flap farthest from her body
C. Removes the outside packaging of a sterile instrument before dropping into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm NOTE: OTHER SOURCES LIST ONLY A & C as the correct answers.
- A nurse is providing care for 4 post-opt clients. The nurse should first assess the client
A. Whose pulse has been steadily increasing during the past shift
B. Who is reporting a pain level of 8 on a scale of 0 to 10.
C. Whose urine output averaged 32 ml/hr for the past 24 hr
D. Who is reporting nausea after the prescribed antiemetic was administered
B. Who is reporting a pain level of 8 on a scale of 0 to 10. - A nurse is preparing to transcribe a client‟s med prescription in the medical record. Which of the following should the nurse recognize as containing the essential components of a medication order?
A. NPH insulin 10 Units before and at bedtime
B. Haloperidol (Hadol) 1mg per mouth
C. Multivit every morning by mouth
D. Aspirin 650 mg by mouth every 4hr
D. Aspirin 650 mg by mouth every 4hr
- A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
A. Recommend that he takes time to plan at the beginning of shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his staffs
D. Offer to provide care for his clients while he takes a break
A. Recommend that he takes time to plan at the beginning of shift
- A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting, which of the following actions should the nurse take first?
A. Remove the client‟s clothing
B. Irrigate the exposed area with water C. Report the incident to OSHA
D. Don personal protective equipment
B. Irrigate the exposed area with water
- A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
A. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min
C. A nurse explains to a client’s family that a DNR order includes withholding comfort measures
D. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better
C. A nurse explains to a client’s family that a DNR order includes withholding comfort measures
- A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of tele health?
A. Assessing client needs
B. Providing med reconciliation
C. Establishing communication between providers
D. Developing client treatment protocols
- Which of the following put a hospital at the highest risk of infringement of client record confidentiality?
A. A nurse clusters documentation of care for multiple clients?
B. A provider and nurse access client info using one access code
C. Paper-based charts are stored at the nurse’s station
D. A nurse performs electronic documentation outside a client‟s room
C. Paper-based charts are stored at the nurse’s station
- Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques?
A. A nurse cleans up blood spill with a 1:10 bleach solution
B. A nurse uses googles to perform tracheostomy suctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen
D. A nurse places a mask on a client with TB before transport to the radiology department
- Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school-age child has several bruises on her lower legs.
B. A toddler cries whenever his parents enters the hospitals room.
C. An Adolescent admitted to the emergency won‟t speak to his parents
D. A preschool child who was previously toilet trained now requires diapers in the hospital
B. A toddler cries whenever his parents enters the hospitals room. - A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse?
A. Liaison
B. Pastoral care provider
C. Health educator
D. Personal Health counselor
POSSIBLE ANSWER
A. Liaison
- A nurse performing triage during a mass casualty incident should recognize that which of the following clients should be transported to the hospital first?
A. A client who reports substernal chest pain radiating to the neck ?????
B. A client who has an open fracture of the femur
C. A client who has a 4-inch laceration on the forearm
D. A client who has a penetrating head injury and fixed dilated pupils
A. A client who reports substernal chest pain radiating to the neck ?????
- A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about client confidentiality
B. Report the incident to the nursing supervisor
C. Remind them that the client info is confidential
D. Fill out an incident report regarding the situation
C. Remind them that the client info is confidential
- A client has a substance use disorder is admitted to the mental health Unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states: “It‟s Ok. Soon everything will be just fine.” Which of the following is the nurse‟s primary first action?
A. Ask the client if he has considered hurting himself
B. Provide the client with info about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with the discharge referral
A. Ask the client if he has considered hurting himself
- A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administer the injection. This illustrate which of the following?
A. False imprisonment
B. Battery
C. Assault
D. Libel
B. Battery
- A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first?
A. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse C. Document a factual description of the situation
D. Remove the nurse from the unit
D. Remove the nurse from the unit
- A nurse observes a paper bag at the bedside of a client. This finding suggest that the client is receiving treatment for which of the respiratory disorders
A. Asthma
B. Hyperventilation
C. Stidor
D. Atelectasis
C. Hyperventilation
- A nurse is preparing the discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?
A. Lab results within the expected reference range
B. List of regularly prescribed meds
C. Date of last bowel movement
D. Level of consciousness
D. Level of consciousness
- A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?
A. Review the client‟s new lab values
B. Document assessment data
C. Complete required tasks
D. Determine client care goals
D. Determine client care goals
- A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed indicates understanding of isolation guidelines?
A. I will instruct visitors to wear a mask when visiting a client who is on contact precaution
B. I will place a client who has compromised immunity in a negative-pressure airflow room
C. I will wear N-95 respirator mask when caring for a client who is on droplet precaution
D. I will have a client who is on airborne precautions wear a mask when out of her
D. I will have a client who is on airborne precautions wear a mask when out of her
- A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring a client to social services for assistance with transportation
C. Instructing a client who is obese about a low-fat diet
D. Providing the first oral feeding to a client following a stroke
A. Changing the dressing on a postoperative wound
- A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury level C-7. Which of the following is the priority action creating the discharge plan?
A. Select strategies for cost-effective home care
B. Identify the client‟s ability to perform activities of daily living
C.Provide educational handouts related to care requirements.
D.Recommend community resources available to assist with client care.
B. Identify the client’s ability to perform activities of daily living
- A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first?
A. A client who has a nasogastric tube to intermittent suction and reports nausea
B. A client who has an early morning blood glucose of 220 mg/dl
C. A client who had a bladder scan that indicated 250 ml of urine in the bladder
D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage
D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage
- A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel
B. Pick up the meal trays after lunch.
C. Administer a nasogastric tube feeding.
D. Determine adequacy of ventilator settings
C. Adminisnister a NG tube feeding
- An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes
D. Frequent dressing changes
- A nurse is caring for 4 clients. Which of the following tasks can be delegated to an assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
C. Obtaining a stool sample from a client with renal failure - A charge nurse is making rounds and observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
A. Inform the unit manager of the incident
B. Remove the restraints from the client’s wrists
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation.
B. Remove the restraints from the client’s wrists
- A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
A. Document the client‟s refusal in the chart
B. Tell the client that a catheter will be inserted
C. Obtain a provider‟s prescription for a blood alcohol level.
D. Assess the client for urinary retention.
A. Document the client‟s refusal in the chart
- Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care.
B. Wait to dispose of sharps containers until they are completely full.
C. Return unused supplies from the bedside to the unit‟s supply stock.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
A. Use clean gloves rather than sterile gloves for colostomy care.
- An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel?
A. Turning the client
B. Recording the client’s vital signs
C. Determining the client’s pain level
D. Checking the pulses of the client’s right foot.
B. Recording the client’s vital signs
- To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies in the nurse manager using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
D. Competing
- A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a med-surg unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida client who is 1 day post-opt following a cesarean section and has a PCA
pump
C. A multigravida client who has preemclampsia and is receiving mistoprostol (Cytotec) for
induction of labor.
D. A client who is at 32 weeks of gestation and has premature rupture of membranes
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
- A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
B. A client who has type 1 DM and uses insulin pump
C. A client who has orthostatic hypotension and is receiving IV fluids.
D. A client who is receiving heparin and has an aPTT of 34 seconds
D. A client who is receiving heparin and has an aPTT of 34 seconds
- A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates an appropriate understanding of these safety procedures?
A. Prophylactic treatment should be initiated after a needlestick during preparation of an injection
B. I should stop the bleeding as soon as possible following a needlestick injury
C. An incident report should be completed if a client receives a stick from her own
used needle
D. The needle should be recapped to prevent injury during transport to the biohazard container.
A. Prophylactic treatment should be initiated after a needlestick during preparation of an injection
- A nurse on a medical surg Unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
A. Obtaining a urine specimen from an older adult client
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Reinforcing dietary teaching with a client who has heart disease
C. Accompanying a client who just had a wound debridement to physical therapy
- A nurse enters the room of a client who is unconscious and finds that the client‟s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first?
A. Recommend the son meet with the provider to get info about his mother‟s condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out of the computer so that the client‟s son is unable to view his mother’s info
D. Report the possible violation of client confidentiality to the nurse manager
C. Log out of the computer so that the client’s son is unable to view his mother‟s info
- A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene?
A. The oxygen machine has a grounded plug
B. Accompanying a client who just had a wound debridement to physical
therapy
C. The family keeps a spare oxygen tank in the room
The window of the client’s room are open
D. The client is covered with a woolen blanket
D. The client is covered with a woolen blanket
- A nurse is teaching a client how to use a finger stick glucometer at home. Which of the following instruction should the nurse include?
A. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in the trash
C. Obtainthebloodsamplefromthefingerpads.
D. Warm the hands prior to piercing the skin
D. Warm the hands prior to piercing the skin
- A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
A. Contact the client’s next of kin to obtain consent for treatment
B. Proceed with treatment without obtaining written consent
C. Have the client sign a consent for treatment.
D. Notify risk management before initiating treatment.
A. Contact the client’s next of kin to obtain consent for treatment
- A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include?
A. The client should avoid using the microwave oven to heat food
B. Regular programming evaluation can be conducted by telephones
C. The client should avoid using remote control devices to prevent dysrhythmias
D. Suctioning could cause the unit to have an electrical shock.
B. Regular programming evaluation can be conducted by telephones
- While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that 6 of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this info on record to the nursing staff.
B. Ask the nurses who are caring for clients without this info in the medical record to obtain it.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Remind nurses to obtain this info during the admission process.
B. Ask the nurses who are caring for clients without this info in the medical record to obtain it.
- A client is admitted with COPD. Which of the following findings should the nurse report to the provider?
A. Oxygen saturation 89% on room air.
B. WBC’s count 9,000/mm
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs.
D. Bilateral crackles on auscultation of lungs
- A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts. Which of the following actions should the nurse take first?
A. Provide coverage for the nurse’s breaks.
B. Determine the reasons the nurses are not taking scheduled breaks
C. Discuss the management strategies with the nurses.
D. Review facility policies for taking scheduled breaks.
B. Determine the reasons the nurses are not taking scheduled breaks
- A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (Select all that apply.)
A. Occupational therapist
B. Nutritional therapist
C. Physical therapist
D. Mental Health counselor
E. Case manager
B. Nutritional therapist
D. Mental Health counselor
E. Case manager
- A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective?
A. Guardian consent is required for an emancipated minor
B. Consent can be given by a durable power of attorney.
C. A family member can answer any questions the client has about the procedure.
D. The nurse can answer any questions the client has about the procedure
A. Guardian consent is required for an emancipated minor
(POSSIBLY INCORRECT)
PERSONAL CHOICE:
B. Consent can be given by a durable power of attorney.
- A nurse on a medical-surg unit is caring for 4 clients. This nurse should recognize that which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
C. A client who is post-opt following a laminectomy 12 hr ago and is unable to void.
D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an axillary temp of 38 degree C ( 101 F)
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
- A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. It’s not too late to cancel the surgery if you want to
B. This won’t take long and it will be over before you know it.
C. Why did you make the decision to have this procedure
D. You shouldn’t be worried because the procedure is very safe
A. It’s not too late to cancel the surgery if you want to
- A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A. A client who has a raised red skin rash on his arms, neck, and face
B. A client who reports right-sided flank pain and is diaphoretic
C. A client who reports shortness of breath and left neck and shoulder pain
D. A client who has active bleeding from a puncture wound in the left groin
C. A client who reports shortness of breath and left neck and shoulder pain
- A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first in the quality improvement process?
A. Review current literature regarding client falls.
B. Implement a fall prevention plan
C. Notify staff of the increased fall rates
D. Identify clients who are at risk for falls
D. Identify clients who are at risk for falls
- A nurse is evaluating a newly licensed nurse who is administering a vitamin K (Aquamephytoin) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.)
A. Selects the dorsogluteal site to administer the injection
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
D. Aspirate the syringe for blood return after needle insertion
E. Inserts the needle at a 45 degree angle.
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
- A nurse enters a client’s room and observes a fire in a trash can. Identify, the sequence of actions the nurse should take. (Move all the actions into the box on the right, placing them in the selected order performance.)
- Remove the client from the area
- Activate the fire alarm system
- Confine the fire by closing doors and windows
- Extinguish the fire if possible
Hint: Remember RACE mnemonic
- Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Telling a client who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Threatening to apply wrist restraints to control a client who is agitated
C. Inserting a feeding tube against the wishes of a client who refuses to eat