A nurse is reviewing a client's medication administration record and finds that the client has not received a prescribed dose of warfarin for 2 days. which of the following actions should the nurse take first?
answer
Check the client's INR.
question
A nurse manager is presenting an in-service about preventing readmission of clients dues to complications following joint arthroplasty. Which of the following leadership tasks is the nurse performing?
answer
Advocay
question
a nurse is teaching an AP about caring for a client who has a DNR order. Which of the following statements by the AP indicates an understanding of the teaching?
answer
"I will call for the client's nurse to come to the room if I cannot detect the client's pulse."
The AP should contact the nurse for further assessment whenever a client's condition does not meet expected findings. The client who has a DNR order in place does not require resuscitation.
question
A nurse is caring for four clients. Which of the following tasks can the nurse assign to an AP?
answer
Perform chest compressions on a client who is in cardiac arrest.
The nurse should assign an AP to perform chest compressions on a client who is in cardiac arrest. Performing basic CPR is within an AP's range of function.
question
A Nurse is teaching a newly licensed nurse about using electronic medical records. which of the following statements by the newly licensed nurse indicated an understanding of the teaching?
answer
"My access to client electronic medical records may be tracked by my nurse manager."
The nurse should keep her password private and not share it with anyone else to decrease the risk for a breach of client confidentiality.The nurse should expect her employer to track access of client records to ensure client confidentiality.While a client has the right to read his medical record, and the nurse can allow him to do so by following facility protocol, a client's partner does not have that right unless granted by the client.The nurse should log out of the electronic medical record when not actively using it. Failure to log out increases the risk for breach of client confidentiality.
question
a nurse is receiving change-of-shift report. which of the following clients should the nurse assess first?
answer
A client who had abdominal surgery 6 hours ago and had a heart rate of 120/min for the last 2 hours.
question
A RN delegates the task of obtaining the bp of a client who is 2hr post-op following a cholecystectomy to a LPN. The LPN reports a BP that is significantly higher than the clients previous reading. which of the following actions should the RN take first?
answer
Recheck client's BP
question
A public health nurse is developing a list of recommendations for her supervisior on how to use EBP to improve community outcomes. Which of the following should the nurse recommend as a qualitative research method?
answer
Phenomenology
Meta-analysis is a quantitative research method that provides a statistical analysis of multiple studies conducted on the same topic.Experimental study is a quantitative research method that uses control and treatment groups to test at least one independent variable.Phenomenology is a qualitative research method that provides additional understanding of participants' experiences with emotional variances, such as grief and hope.Secondary analysis is a quantitative research method that uses previously collected data to answer newly formed hypotheses.
question
A nurse at a urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy?
answer
Report this issue to the nurse manager.
The nurse should report this issue to the nurse manager because it is the manager's responsibility to ensure that standards are met and that care is provided according to policy.
question
A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
answer
"These will outline my wishes for medication treatment."
The purpose of advance directives is to outline the client's wishes if they become unresponsive
question
A nurse is caring for a client who recently learned he has a mutation of the BRCA2 gene. The client states that he does not plan to tell his adult children about the dx. Which of the following responses displays clients advocacy by the nurse?
answer
"Let's review what you understand about this test result."
The nurse should use therapeutic communication techniques to encourage the client to share his point of view and to convey respect for the client's decisions. By seeking to understand the client's perceptions in a nonjudgmental manner, the nurse is displaying client advocacy.
question
A nurse is caring for a client who has breast cancer and is deciding on a plan of treatment. which of the following statements should the nurse make?
answer
"Let's talk about the benefits of each treatment."
Talking about the benefits of each treatment option supports the right of the client to make decisions regarding treatment and encourages comparison of the treatments.
question
A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease?
answer
Chlamydia trachomatis
According to the Centers for Disease Control and Prevention, Chlamydia trachomatis is a nationally notifiable infectious disease in all 51 jurisdictions. The nurse should notify the state health department, which monitors and controls communicable diseases.
question
A staff nurse detects alcohol on the breath of another nurse working on the unit. The staff nurse observes that the nurse's speech is slurred and their gait is unsteady. Which of the following actions should the nurse take?
answer
Notify the charge nurse of the nurse's behavior.
The charge nurse is responsible for the performance of the nurses on the shift; therefore, the staff nurse should follow the chain of command and notify the charge nurse about the nurse's behavior.
question
A nurse overhears two staff members in the facility elevator discussing a clients care. which of the following actions should the nurse take?
answer
Report the incident to the nurse manager.
question
A Nurse manager is reviewing the stages of conflict resolutions with the nursing staff. The nurse manager should instruct the staff to expect the stages of conflict to occur in what order? STEPs:
A nurse is planning discharge care for a client who has rheumatoid arthritis and has difficulty buttoning clothing. Which of the following referrals should the nurse recommend for the client?
answer
Occupational Therapy
question
A nurse has just received report on four clients on a med-surg unit. which of the following clients should the nurse plan to assess first?
answer
A client who is post-op following a total knee arthroplasty and has a cap. refill of 4 secs.
question
A nurse is caring for several clients. which of the following actions should the nurse take to maintain client confidentiality
answer
Tell a client's partner that the clients lab test cannot be disclosed without permission.
question
A Charge Nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the CN take?
answer
Assign the procedure to a LPN
question
A nurse on a med-surg unit is terminally ill. which of the follwoing actions demonstrates that the nurse is practicing in an ethical manner when caring for the client?
answer
Discuss end-of-life goals with the client.
question
A nurse is teaching about the patient protection and affordable care act and their rights regarding insurance coverage. which of the following statements by the client indicates an understanding of the teaching?
answer
"My insurance coverage no longer has lifetime coverage limits."
question
A nurse is delegating tasks for a group of clients to an AP. Which of the following statements by the nurse provides the right direction of communication with the AP?
answer
"Tell me what time the client in room 205 voids for the first time after catheter is removed."
question
A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next?
answer
Inform the client about the risks she may encounter by leaving the facility.
question
A Charge Nurse is evaluating a plan of care that a newly licensed nurse developed for a client who us to received a continuous NG tube feeding. Which of the following interventions should the CN ensure is part of the plan of care?
answer
Use a 60ML syringe to flush out a clogged tube.
question
A CN is planning assignments for the upcoming shift. Which of the following tasks should the CN delegate to an AP?
answer
Assisting a client who had a hip arthroplasty to a chair.
question
A Nurse manager is conducting an annual performance review for a staff nurse. Which of the following strategies should the nurse use in the review process? Select all that apply
answer
Include peer evals completed by other staff nurses
Have the nurse conduct a self-appraisal prior to review
Complete a performance checklist
question
A nurse manager is reviewing the actions a staff nurse took when they observed smoke coming from the wastebasket in a client's room. The nurse manager should verify that the nurse acted appropriately when they performed which of the following actions first?
answer
Transported the client to the hallway.
question
A nurse is caring for a client who is experiencing adverse effects after receiving a new medication. Which of the following communication tools should the nurse use for management of this complication?
answer
SBAR Framework.
question
A CN on a medical unit hears the fire alarm announcement that a fire is occurring on the unit. which of the following is priority action by the CN?
answer
Instruct ambulatory clients to go to a safe area.
question
A nurse manager is completing a performance improvement audit and determines documentation of clients discharge teaching is below the expected benchmark. Which of the following actions should the nurse implement first?
answer
Determine the factors that interfere with the documentation of clients education.
question
A CN is conducting an in-service with staff members about infection control precautions. The nurse should instruct the staff that which of the following clients requires droplet precautions.
answer
A client with pertussis.
question
A CN has been asked to determine staff adherence to established standards for post-op vital sign measurement. Which of the following actions should the nurse take to collect information?
answer
Conduct a retrospective chart audit of all surgical clients for the past 6 months.
question
A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's priority?
answer
Assign client care to staff.
question
A nurse in the Emergency Department is performing triage for a group of clients following motor-vehicle crash. Which of the following clients should the nurse request the provider assess first?
answer
A client who has arm contusions and manifest asymmetrical thoracic movement.
question
A nurse is teaching a newly licensed nurse about telephone prescription guidelines. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
answer
i should repeat the prescription back to the provider
question
A RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of following activities must be performed by the RN?
answer
Completing the clients initial admission assessment.
question
A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
answer
I should complete an incident report for an unexpected client occurrence.
question
A CN is managing conflict with a staff nurse who does not agree with the clients care assignment. which of the following statements is an example of using conflict resolution straegy known as smoothing.
answer
You always complete your work on time and do a great job. i believe you can handle this assignment well.
question
A nurse is caring for a client who has an informed consent form for an upcoming procedure in his health record. Which of the following actions should the nurse take to validate that the client understands the procedure.
answer
Ask the client to verbalize the purpose, risks, and benefits of the procedure.
question
A nurse is planning discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?
answer
Home Health
question
A nurse is reviewing safe use of a wheelchair with a group of assistive personal. Which of the following instructions should the nurse include?
answer
Raise the footplates of the wheelchair before transferring the client.
question
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?
answer
Compare data from client's records regarding skin integrity with established criteria.
question
A nurse from a medical unit is asked to work on a orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?
answer
a client who had the right above-the-knee amputation 24 hrs ago.
question
A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take?
answer
Assist in weighing the options involved in the decision.
question
A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. which of the following should the nurse manager include in the teaching?
answer
Verify that the provider prescription is in the medical record for the clients who have restraints.
question
A nurse manager is teaching about confidentiality requirements to a staff. which of the following staff comments indicates an understanding of the teaching?
answer
Change-of-shift report can be given at the client's bedside.
question
A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. which of the following information can assist the nurse in evaluating the cost effectiveness of the care?
answer
The length of the client's stay.
question
A nurse is caring for a client who reports vomiting and diarrhea for the past 6hr. The nurse should identify that which of the following assessments is the priority?
answer
Obtain the client's serum potassium level.
question
The AP tells a CN that it is unfait that they have to take care of all the clients who are incontinent. Which of the following responses should the CN make?
answer
I delegate tasts to personal based on their job descriptions.
question
A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the CN make?
answer
Clients are the experts on their own pain.
question
A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?
answer
Ask the client to explain the procedure that is being performed.
question
A nurse in the emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?
answer
A client who has a sucking chest wound.
question
A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the CN?
answer
A nurse is photocopying their assigned client's diagnostic test results.
question
A CN is observing a newly licensed nurse's use of time-management skills. Which of the following actions by the newly licensed nurse indicates effective use of the skill?
answer
Groups tasks that are in the same location.
question
A nurse is caring for a client who has terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?
answer
Your case manager will coordinate the resources you will need.
question
A CN is leadind a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?
answer
Determine the goals and objectives.
question
A nurse is caring for a client who requests pain medications. The nurse fulfills a promise to return with the medications within 15min. The nurse is demonstrating which of the following ethical principles?
answer
Fidelity.
question
A nurse is caring for a client who is 3-days post-op following open heart -surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?
answer
The client's level of consciousness
question
A nurse receives notification of a fire on the unit. Which of the following should the nurse take first?
answer
Assist clients who are in immediate danger to a safe location.
question
A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has central venous catheter. Which of the following actions should the newly licensed nurse take?
answer
Pick up the first sterile glove by grasping the folded cuff edge.
question
A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?
answer
This is a procedure that does not require a written informed consent.
question
A client is being discharged with a post-op infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge?
answer
Ensure that home infusion therapy has been arranged.
question
A nurse is speaking with the adult child who has severe Alzeimer's disease. The child is crying and tells the nurse. "i dont know how much longer i can keep this up" Which of the following responses should the nurse make?
answer
Lets discuss options for respite care.
question
A nurse is caring for a client who is scheduled for rotator cuff surgery. The client tells the nurse, "my should doesnt hurt that bad. i want to wait on the surgery. which of the following responses should the nurse give?
answer
i will notify your provider of your decision.
question
A nurse case manager is planning a teaching session on the use of critical pathways with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching?
answer
Critical pathways prevent unnecessary expense.
question
A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict?
answer
I'm not sure whether i want to apply for the unit manager's position or start a family this year.
question
A CN is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions?
answer
After i finish with the printout of my assignments, i will put it in the shredder receptacle.
question
A nurse manager sends home a nurse who is chemically impaired. Which of the following actions should the nurse manager take?
answer
Set up a formal meeting with the nurse within 24hr.
question
A nurse in a mental health facility is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
answer
i should request the provider to examine the clients within 1-hour of applying the mechanical restraints.
question
A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priory to report to the charge nurse?
answer
A client who is 2 days post-op and has a urine output of 20 ML/HR
question
A facility has identified an increase in health-care associated urinary tract infection (UTIs) on the medical-surgical unity. A nurse is participating in quality improvement process to address this problem. Which of the following should be the first step in the process.
answer
Establish best practice guidelines for reducing the incidence of UTIs.
question
A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enternal nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feeding. Which of the following actions should the nurse take?
answer
Review the client's request with the family.
question
A CN is observing a newly licensed nurse care for a client who has a prescription for application of an aquathermia pad to the right lower leg. Which of the following actions should indicate to the charge nurse that the nurse understands how to use this device? Select all that appy
answer
Asks the clients to report it the aquathermia pad gets too warm
Ensures that the client's call light is within reach
question
A nurse is caring for a client who has a potassium level of 3.2 mEq/K. The nurse has been paging the provider for 1 hr to attempt to report the potassium level. Which of the following actions should the nurse take next?
answer
Notify the nursing supervisor.
question
A nurse is caring for a client who has renal failure. The client tells the nurse that they have decided to stop hemodialysis treatment. which of the following actions should the nurse take to act in the role of an advocate for this client?
answer
Support the client's decision regarding treatment.
question
a nurse is teaching a newly licensed nurse about using electronic medical records. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
answer
My access to the client electronic records might be tracked by my nurse manger.
question
A nurse is assessing a client who is post-op and has a PCA. The client exhibits restlessness, an elevated pulse, and decrease in BP. Which of the following actions should the nurse take?
answer
Place the client in a modified Trendelenburg position.
question
A CN is planning care for a group of clients. which of the following tasks should be delegated to an AP. Select all that apply
answer
Ambulating
Adding thickener to thin liquids
question
There has been a massive community disaster and stable clients must be discharged from a facility to prepare for the influx of new casualties. A nurse should identify that which of the following clients is safe to discharge?
answer
A client who has multiple sclerosis and reports ataxia.
question
A nurse is reviewing the components of a surgical informed consent with a newly licensed nurse. Which of the following statements should the nurse include?
answer
The nurse should ensure the client understands the information given by the surgeon.
question
a nurse is presenting information on health care law to a group of newly licensed nurses. Which of the following information should the nurse include?
answer
The patient self-determination Act (PSDA) requires a nurse to give clients information about end-of-life options
question
A charge nurse notices that a newly hired nurse consistently does not finish client care tasks by the end of the shift. Which of the following statements should the charge nurse make?
answer
you should set aside a time to plan your day at the beginning of each shift.
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