VATI ATI Leadership Management

Providing the client with a back massage can assist the client with pain management. However, this is not a demonstration of client advocacy, which involves intervening on the client's behalf.

Recommend the client watch television as a distraction from the pain.

Distraction, such as watching television, can assist a client with pain management. However, this is not a demonstration of client advocacy, which involves intervening on the client's behalf.

Attempt to obtain a prescription for a different analgesic medication. 

MY ANSWER

The role of the nurse as a client advocate involves directly intervening on behalf of the client. The nurse should attempt to obtain a prescription from the provider for a different analgesic medication to manage the client's pain.

Inform the client that they can receive their next dose in 3 hr. 

The nurse should tell the client when they can receive their next dose of the medication to keep the client informed of the treatment plan. However, this is not a demonstration of client advocacy, which involves intervening on the client's behalf.Bottom of Form

3.

A charge nurse is teaching a newly licensed nurse about providing written discharge instructions for a client who is postoperative following an arthroplasty. The charge nurse should identify that which of the following discharge instructions written by the newly licensed nurse indicates understanding of the teaching?

Take oxycodone 10 mg, q6h, PRN, for pain.

The nurse should avoid using medical terminology when providing written instructions to the client because the client can have difficulty understanding the information.

Report pus-like drainage from the wound.

MY ANSWER

The nurse should provide clear descriptions in terms the client can understand when providing written discharge instructions. The nurse should also ensure the client is aware of what complications to report to the provider.

Resume Na-restricted diet.

The nurse should avoid using abbreviations in written discharge instructions because the client can have difficulty understanding the information.

Perform quadriceps setting exercises when supine.

The nurse should provide step-by-step instructions on how to perform quadriceps setting exercises when lying supine and avoid using vocabulary that the client can have difficulty understanding in the written discharge instructions.Bottom of Form

4.

A nurse is using the SBAR communication tool for reporting a client's condition to the provider. Which of the following information should the nurse include in the 'S' portion of the tool?

The client was medicated with morphine 2 mg IV 1 hr ago.

This information provides medical information that is pertinent to the client's condition and is part of the background portion (B) of the SBAR communication tool.

The client needs a change in pain medication prescription.

MY ANSWER

This information provides a potential solution for the client's current need and is part of the recommendation portion (R) of the SBAR communication tool.

The client is reporting a pain level of 8 on a scale from 0 to 10. 

This information provides a brief explanation of the current situation and is part of the situation portion (S) of the SBAR communication tool.

The client has a heart rate of 110/min and a BP of 148/88 mm Hg.

This information provides recent assessment data indicating the client's current condition and is part of the assessment portion (A) of the SBAR communication tool.

5.

A nurse manager is anticipating a period when staffing will be especially short. The nurse manager decides to reorganize the delivery of care on the unit until staffing improves by appointing a charge nurse, a medication nurse, and a treatment nurse. Which of the following delivery systems is the nurse manager using?

Primary nursing

Primary nursing is a form of total client care in which one nurse has 24-hr responsibility and accountability for the nursing care of specific clients for the duration of their stay at the facility. Primary nursing promotes clear communication among the health care team.

Team nursing

MY ANSWER

Team nursing is the most common nursing care delivery system. The nurse manager divides the nursing staff into teams, including staff of various skills and licensure. Each team provides total care to a specific group of clients and has a team leader.

Functional nursing

Functional nursing, also called task nursing, involves the nurse manager breaking down the needs of the clients into tasks and assigning the tasks using the skill and licensure of each staff member appropriately and efficiently. This model of nursing is uncommon in acute care settings, except in crisis situations, or when there is a shortage in staffing numbers.

Modular nursing

Modular nursing is a type of team nursing in which a manager assigns a team of staff, often called care pairs, with various skills and licensure to a given geographic area, or module. An example of modular nursing is assigning a team to a group of clients' rooms.

6.

A nurse manager is preparing a nurse's performance appraisal. Which of the following actions should the nurse manager take?

Avoid using specific examples of client care to maintain confidentiality.

The nurse manager should include specific examples that occur throughout the appraisal period and avoid generalities about the nurse's performance of client care during the performance appraisal.

Focus on the nurse's most recent performance just before the evaluation.

The nurse manager should focus on the nurse's performance throughout the appraisal period by collecting data systematically and on a regular basis. Otherwise, recent performance will likely be more heavily evaluated than past performance.

Present goals to the nurse at the initial meeting.

MY ANSWER

The nurse manager should set goals together with the nurse during the performance appraisal.

Use a formalized system to discuss important issues. 

The nurse manager should use a formalized system to determine the employee's level of meeting the objectives for their job. The goal of performance appraisal is to promote growth for the employee and provide recognition for areas of strength along with feedback for areas of concern.

7.

A nurse in an acute care facility is caring for a client who is leaving against medical advice (AMA). Which of the following actions should the nurse take? (Select all that apply.)

Attempt to detain the client.

Request the client sign an AMA form.

Notify the provider of client's intent.

Sedate the client while waiting for the provider to arrive.

Advise the client about the dangers of leaving.

MY ANSWER

Attempt to detain the client is incorrect. The nurse has no authority to detain a client. Furthermore, this action is considered a of type of restraint.

Request the client sign an AMA form is correct. The nurse should ask the client to sign an AMA form to document the incident. A signed AMA form can assist with a counterclaim of negligence.

Notify the provider of client's intent is correct. The nurse should immediately notify the provider of the client's intent to leave AMA.

Sedate the client while waiting for the provider to arrive is incorrect. The nurse should not sedate the client while waiting for the provider to arrive because this could be considered the use of a chemical restraint and is in direct opposition to the client's wish to leave.

Advise the client about the dangers of leaving is correct. The nurse should discuss the potential dangers of leaving AMA, such as complications of the client's medical condition.

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8.

A nurse is using the situation, background, assessment, recommendation (SBAR) format to provide hand-off report for a client. In which of the following components of the SBAR report should the nurse include information about the client's current vital signs?

Situation

The nurse should include the nurse's name, the client's name, the name of the facility, the client's medical diagnosis, and a general description of the client's situation in the situation (S) section of the SBAR report.

Background

The nurse should provide information relevant to the client's condition such as the client's admitting diagnosis and any surgical procedures in the background (B) section of the SBAR report.

Assessment

MY ANSWER

The nurse should include findings such as current vital signs, pain level, and appearance of a wound dressing in the assessment (A) section of the SBAR report

Recommendation

The nurse should provide information on how to resolve a problem or improve client care in the recommendation (R) section of the SBAR report.

9.

A charge nurse in an acute care facility is teaching a newly licensed nurse about caring for an adult client who is cognitively impaired. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? 

'I will let the client sit at the nurses' station during the day.'

The newly licensed nurse should place the client in a location where she can be frequently observed. However, the newly licensed nurse should not place the client at the nurses' station. Confidential information about other clients is kept at the nurses' station and the client should not be allowed into this area. The area behind the desks is for facility personnel only.

'I will assign the client to a room close to the nurses' station.' 

MY ANSWER

The newly licensed nurse should assign the client to a room close to the nurses' station so the newly licensed nurse can closely monitor the client.

'I will elevate full-length bed rails while the client is in bed.'

The newly licensed nurse should lower the bed to the lowest level and apply 1/4- to 3/4-length bed rails to prevent the client from climbing over the rails and falling.

'I will place a red wrist band on the client to indicate fall risk.'

The newly licensed nurse should place a yellow wrist band on the client, which is the standard color for fall risk recommended by the America Hospital Association. Red bands are recommended for allergy information.Bottom of Form

10.

A nurse manager on a maternal newborn unit is completing a chart audit to determine the percentage of clients over the past 3 months who breastfed their newborns successfully prior to discharge. Which of the following standards is the nurse using to complete this audit?

Structure

Structure standards focus on the internal characteristics of a facility and its staff. These standards help determine if a facility has a structure that promotes high-quality care. An example of a structural standard is ensuring a nursing department provides opportunities for staff development .

Outcome

MY ANSWER

Outcome standards measure whether the services the nurses provide make any difference in a client's health status. The outcome would be a change in clients' current or future health status as a result of the care they received. Other examples of outcome standards include clients ambulating without assistance or clients who have clear breath sounds.

Process

Process standards focus on how well a facility conducts its activities. An example of a process standard is staff measuring vital signs every hour unless otherwise specified.

Practice

Practice standards are guidelines for professional performance that address a wide variety of aspects of nursing care delivery. Practice standards focus on the nurse as a provider, are process-oriented, and relate to expectations for the provider to achieve the standard of care. An example of a practice standard is basing care planning on client assessment and identification of specific nursing diagnoses.Bottom of Form

11.

A nurse manager is changing the ratio of registered nurses (RNs) to licensed practical nurses (LPNs) on a unit to decrease costs. Which of the following strategies should the nurse manager implement to reduce resistance from the staff?

Send a memo to each staff member announcing the new RN/LPN ratio.

Announcing a change is not a strategy to reduce staff resistance. Staff should also have the opportunity to provide input related the change.

Assign the staff to read research articles about the process of change.

Although assigning research articles for the staff to read can help the nursing staff understand how change happens, it is not a strategy to reduce staff resistance. Most resistance is related to individual values, background, experience, and education levels.

Formulate a sample staffing schedule covering 1 month.

MY ANSWER

The nurse manager should include the staff in the process by formulating a sample staffing schedule covering 1 month so that the staff can view the schedule and provide feedback. Resistance to change is an integral part of the process of change. A common reaction to scheduling changes is a fear of loss of hours and lack of trust of the employer.

Discuss the planned change with other nurse managers.

The nurse manager can discuss the change with other nurse managers if the other nurse mangers have implemented similar changes. However, this does not help reduce the staff's resistance to the change.

12.

A nurse is preparing a client for a surgical procedure to continue the revision of a large burn scar on the left arm. The client tells the nurse that they want to cancel the procedure. Which of the following responses should the nurse make?

'This procedure will improve the appearance of your arm.'

The nurse should not offer opinions or pass judgment about the client's decision to refuse treatment. The nurse should encourage the client to make his own decisions regarding his care.

'Why have you changed your mind about this procedure?'

The nurse should not question or challenge the client's decision to refuse treatment. This can cause the client to feel defensive, and it blocks open communication about the client's concerns.

'I will inform the provider of your decision.'

MY ANSWER

The nurse should recognize that the client has the right to refuse treatment at any time. Therefore, the nurse should notify the provider of the client's decision to refuse treatment.

'Don't worry, this is a routine procedure.'

The nurse should not offer false reassurance. This can block communication about the client's concerns about the procedure.

13.

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? 

A client who requests sumatriptan for a migraine

The nurse should check this client's pain level and administer the medication if it is indicated to treat the client's migraine and to relieve pain. However, there is another client the nurse should assess first.

A client who is postoperative and has respiratory rate of 10/min

MY ANSWER

When using the airway, breathing, circulation approach to client care the nurse should assess the client who is postoperative and has a respiratory rate of 10/min first. A respiratory rate of 10/min is below the expected reference range of 12 to 20/min and can indicate that the client is experiencing an adverse effect from anesthesia or pain medication.

A client who is immobile and has a reddened coccyx

The nurse should further assess the condition of this client's skin to determine the level of injury. However, there is another client the nurse should assess first.

A client who is scheduled for a sterile dressing change

The nurse should perform the scheduled sterile dressing change for this client. However, there is another client the nurse should assess first.

14.

A nurse manager suspects that a staff nurse on the night shift has a substance use disorder. Which of the following actions should the nurse manager take?

Discuss the situation with the facility administrator.

The nurse manager should discuss the situation with the nurse supervisor rather than the facility administrator.

Document thoroughly any unusual behavior by the nurse. 

MY ANSWER

The nurse manager should collect reports from other employees, client concerns, and observations, as well as statements detailing any related incidents that support the nurse manager's suspicion that substance use may be involved. The nurse manager can then refer the nurse to an employee assistance program.

Impose a 2-week suspension with a strong recommendation for rehabilitation.

The nurse manager should remove the nurse from the nursing staff and client care, make arrangements for the nurse to go home, and then have a formal meeting within 24 hr, if there is confirmation that the nurse has a substance use disorder.

Counsel the nurse before referring the nurse for help.

The nurse manager's priority after confirming the staff nurse has a substance use disorder is to refer the staff nurse for professional help. The nurse manager should avoid assuming the role of counselor because the nurse who is chemically impaired can manipulate or become dependent on the nurse manager.

15.

A nurse is teaching a group of newly licensed nurses about caring for a client who has Clostridium difficile. Which of the following instructions should the nurse include in the teaching? 

Wear a surgical mask when caring for the client.

A nurse should wear a surgical mask within 1 m (3.3 ft) of a client who requires droplet precautions. A client who has C. difficile does not require droplet precautions.

Use chlorhexidine for hand hygiene after providing care for the client. 

A nurse caring for a client who has C. difficile should use soap and water when performing hand hygiene. Chlorhexidine is ineffective against spores.

Assign the client to a positive airflow room. 

The nurse should assign clients who require a protective environment to a positive airflow room. A client who has C. difficile does not require a positive airflow room.

Put on a gown when caring for the client. 

MY ANSWER

A client who has C. difficile requires contact precautions. Therefore, the nurse should wear an isolation gown and gloves when providing care.

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16.

A nurse manager is meeting with a staff nurse who is consistently late for work. Which of the following statements by the nurse manager demonstrates an assertive communication style?

'When you come to work late, I am concerned that client care will be jeopardized.'

MY ANSWER

The nurse manager's statement is an example of assertive communication. It focuses on the impact the staff nurse's behavior has on the function of the unit. 'I' statements are essential for conveying concerns.

'If you're late one more time I'm going to fire you.'

The nurse manager is using aggressive communication by threatening to fire the nurse without proceeding through the steps of disciplinary action. Aggressive communication is a form of attack that reflects feelings of frustration and anger from the nurse manager.

'No one here likes it when you are late for work and it makes the other staff unhappy. Try to get here on time.'

The nurse manager is using a defensive response by ignoring the real issue and focusing on defending the health care team. The nurse manager's statement does not clearly address the issue or the effect the staff nurse has on the unit for arriving to work late.

'You disappoint me when you come in late.'

The nurse manager is using blame and disapproval to address the staff nurse's issue of consistently arriving late for work. This form of communication can create a negative feeling in the staff nurse and create a barrier for further discussion about the issue.

17.

A nurse manager is implementing a plan to motivate unit personnel to provide quality care to clients on the unit. Which of the following leadership strategies should the nurse manager implement to improve client care?

Democratic leadership 

Democratic leadership is a style that involves two-way communication and fosters teamwork, goal accomplishment, and the individual worth of each staff member. It is most appropriate among a group of mature employees who work well together.

Transactional leadership

Transactional leaders are passive, rather than proactive, in the work environment. Transformational leadership could be used in this situation to inspire staff to work as a group to achieve quality care.

Laissez-faire leadership

MY ANSWER

Laissez-faire leadership is a style that involves two-way communication where the leader provides little or no direction, is permissive, and does not criticize. The nurse manager will not be able to promote quality without providing specific direction to the staff.

Authoritarian leadership

Authoritarian leadership is a style that involves one-way communication and is required in certain situations using direct commands that limit decision making by others. As an example, emergency situations require immediate action and an authoritarian approach, which allows the leader to retain ultimate authority when emergency situations arise. Authoritarian leadership often decreases staff's internal motivation.

18.

A nursing supervisor in an acute care facility has to recommend a client for discharge to make room for a client who was injured during an explosion. Which of the following clients should the nurse recommend for discharge?

A young adult client who has a new diagnosis of diabetes insipidus

The nurse should recommend a client who is medically stable for early discharge from the acute care facility. A young adult client who has a new diagnosis of diabetes insipidus requires acute medical care.

An adult client who is on telemetry for dysrhythmias

The nurse should recommend a client who is medically stable for early discharge from the acute care facility. An adult client who is on continuous ECG monitoring for dysrhythmias requires acute medical care.

An older adult client who had a total knee arthroplasty 1 week ago 

MY ANSWER

The nurse should recommend a client who is medically stable for early discharge from the acute care facility. The nurse should select the older adult client who had a total knee arthroplasty 1 week ago for discharge to a rehabilitation facility or home to receive home health services.

An adult client who had a bowel resection 1 day ago

The nurse should recommend a client who is medically stable for early discharge from the acute care facility. An adult client who had a bowel resection 1 day ago requires acute medical care for at least 72 hr.Bottom of Form

19.

A nurse manager is performing a record audit as part of the unit's quality improvement program. The nurse should identify that which of the following examples demonstrates the correct use of approved abbreviations in a medical record?

Zolpidem 5U PO at bedtime

The nurse can misinterpret 'U' for '0' or '4.' In this case, the medication is not available in units, so the nurse should clarify this prescription with the provider.

Zolpidem 5 mg PO at bedtime

The nurse is using the correct abbreviations and wording during documentation in the medication administration record.

Zolpidem 5 mg PO QD at hs

MY ANSWER

The nurse can misinterpret 'QD' for 'QID,' 'qid,' or 'OD.' The nurse should document using the term 'daily.' The nurse can increase the risk for medication error when using 'hs,' which can also mean 'half strength.' The nurse should document using the term 'bedtime.'

Zolpidem 5.0 mg PO at hs

The nurse can misinterpret the trailing zero in '5.0' for '50' if the decimal point is not marked clearly. The nurse can increase the risk for medication error when using 'hs,' which can also mean 'half strength.' The nurse should document using the term 'bedtime.'

20.

A charge nurse is planning an in-service for a group of nurses about caring for clients who have active tuberculosis. Which of the following information should the charge nurse include in the in-service?

Place clients in a negative pressure room.

MY ANSWER

The nurse should place clients who have active tuberculosis in a private negative pressure room with a minimum of six air exchanges per hour. Air from the room is exhausted directly to the outside. The nurse should also wear an N95 mask prior to entering the room.

Plan to admit clients to a semiprivate room with a client who has the same illness.

Clients who have tuberculosis require airborne isolation precautions, and staff should plan to place them in a private room to prevent spread of the infection. Clients who require droplet or contact precautions can cohort with another client infected with the same microorganism, if needed.

Initiate droplet precautions for these clients.

The nurse should initiate airborne precautions, not droplet precautions, for a client who has active tuberculosis. Airborne precautions involve placing clients in a private room with negative pressure. The nurse should also wear an N95 mask at all times when providing care for a client who requires airborne precautions.

Instruct visitors to stand 1.83 m (6 ft) away from clients.

The nurse should instruct visitors to stand at least 1.83 m (6 ft) away from clients who have sealed radioactive implants to minimize exposure to radiation. Everyone who enters the room of a client who as active tuberculosis should wear a mask.

21.

A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses discussing the biopsy results of a client who is on the unit. Which of the following actions should the nurse take? (Select all that apply.)

Tell the nurses to lower their voices when discussing a client.

Plan an in-service program for the nurses about HIPAA privacy rules. 

Ask the nurses to stop discussing the client's protected health information. 

Inform the nurse manager about the confidentiality breach. 

Complete an incident report about the nurses' breach of confidentiality.

MY ANSWER

Tell the nurses to lower their voices when discussing a client is incorrect. This action implies that it is acceptable to discuss a client's protected health information in a public location. Nurses should only discuss care for clients to which they have been assigned and should do so in a private setting, never in a public place.

Plan an in-service program for the nurses about HIPAA privacy rules is correct. The nurse should plan an in-service program about HIPAA privacy rules for the nurses because it will reinforce the importance of protecting client confidentiality.

Ask the nurses to stop discussing the client's protected health information is correct. The nurse should take immediate action to inform the nurses that they have breached the client's confidentiality and to stop sharing information about the client.

Inform the nurse manager about the confidentiality breach is correct. It is possible that the nurses misunderstood their responsibility to adhere to HIPAA privacy rules. The nurse manager is the appropriate person to reteach these basic legal concepts and can assist in providing an in-service.

Complete an incident report about the nurses' breach of confidentiality is incorrect. An incident report should be completed for an unusual or unexpected event such as a client fall, medication error, or other occurrence that results in physical harm to the client. A breach of confidentiality does not require completion of an incident report.

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22.

A nurse is providing care to a group of clients. Which of the following steps should the nurse plan to take to manage time effectively? (Select all that apply.)

Document completed nursing interventions at the end of the day.

Complete small tasks first that require the least amount of time and energy.

Organize tasks around the priority needs of the clients. 

Create a list of all planned activities. 

Delegate tasks to assistive personnel. 

MY ANSWER

Document completed nursing interventions at the end of the day is incorrect. The nurse should document nursing interventions as soon as the tasks are completed. Waiting until the end of the day to document nursing interventions increases the risk for error.

Complete small tasks first that require the least amount of time and energy is incorrect. The nurse should complete large tasks that require the most time and energy at the beginning of the shift when their energy levels are high.

Organize tasks around the priority needs of the clients is correct. The nurse should organize tasks around the priority needs of the clients to decrease the risk of needs not being met in a timely manner.

Create a list of all planned activities is correct. The nurse should create a list of all planned activities to ensure that they are meeting their goals and managing their time effectively.

Delegate tasks to assistive personnel is correct. The nurse should delegate appropriate tasks to assistive personnel to ensure that they are meeting their goals and managing their time effectively.

23.

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A nurse manager is evaluating staffing needs for a unit, including the need for overtime hours. Which of the following actions should the nurse manager implement first? 

Develop a written defense of the need for overtime hours to present to the administration.

The nurse manager should investigate and validate the reasons for paying for overtime hours and prepare to defend the cause of overtime if administrators have questions. However, there is another action the nurse should take first.

Remind staff members of the importance of avoiding overtime hours.

The nurse manager should remind the staff of the importance of avoiding overtime hours to decrease budgetary requirements. However, there is another action the nurse should take first.

Access computerized data correlating client acuity, staffing, and scheduling. 

MY ANSWER

The first action the nurse manager should take using the nursing process is to assess acuity, staffing, and scheduling needs. Nurse managers have a responsibility to ensure that the staff delivers cost-effective, high-quality care. Collecting data that supports decision-making can help managers monitor and correlate staffing, client acuity levels, and scheduling patterns in relation to budget requirements.

Graph the number of overtime hours in relation to staff to support the need for more staff.

The nurse manager should graph the number of overtime hours in relationship to staffing on a regular basis. However, there is another action the nurse should take first.

24.

A nurse is delegating client care on a labor and delivery unit. Which of the following tasks should the nurse delegate to assistive personnel (AP)?

Instruct a client about breathing techniques.

Teaching a client is not within the range of function for an AP. The nurse should not delegate this task to an AP because it involves providing technical information and evaluating the client's understanding.

Complete I&O on clients who are in active labor. 

MY ANSWER

Completing intake and output on a client is a basic task the nurse can delegate to an AP and is within the AP's range of function.

Obtain a fetal heart rate from a client who is a primipara and is in early labor.

Obtaining a fetal heart rate is a task that requires technical skill. It is performed by a provider, nurse practitioner, or specially trained registered nurse and is not within the range of function for an AP.

Obtain consent from a client for cesarean birth.

Obtaining consent from a client for cesarean birth requires nursing knowledge and skill. The nurse should not delegate this task to an AP because it is not within the range of function for an AP to legally obtain informed consent.

25.

A nurse is providing discharge teaching to a client's adult child regarding the client's discharge to home with hospice care. Which of the following statements by the client's adult child indicates an understanding of the teaching?

'Once my father is home with hospice, he can no longer be admitted to the hospital.'

Hospice care can be provided at home or in a skilled nursing facility, which can become necessary as the client's condition declines or if family is no longer able to care for the client at home.

'I understand that hospice services are out-of-pocket expenses for the family.'

A client is eligible for hospice care or hospice care benefits when a provider certifies the client is likely to die within 6 months. The hospice nurse serves as a case manager to assist the client in finding appropriate resources and services as needed.

'Participating in a hospice program should enable my father to live longer.'

Hospice services do not focus on life-saving measures to prolong life, but rather on improving or maintaining the client's quality of life until death.

'The hospice team will provide services for the entire family, not just my father.' 

MY ANSWER

Hospice services are provided by a team of health care professionals and nonprofessionals that offer a full range of services, supporting both the client and family through the dying process.

26.

A nurse is planning care for a client who has hemiparesis and dysphagia following a stroke. The nurse should collaborate with which of the following members of the interprofessional team to assist the client with managing ADLs? (Select all that apply.)

Occupational therapist

Physical therapist

Audiologist

Respiratory therapist

Speech-language pathologist

MY ANSWER

Occupational therapist is correct. An occupational therapist helps clients who have physical limitations or disabilities gain an optimal level of independence to perform ADLs, such as bathing, dressing, grooming, and eating.

Physical therapist is correct. A physical therapist can assess the client's strength and mobility, implement therapeutic strategies, and teach new skills to help compensate for physical limitations to help manage ADLs.

Audiologist is incorrect. An audiologist specializes in assessing and determining hearing loss. There is no indication that the client needs a hearing assessment.

Respiratory therapist is incorrect. A respiratory therapist can administer pulmonary function tests and assist in providing therapies, such as oxygen, to help manage respiratory health. There is no indication that the client needs respiratory support.

Speech-language pathologist is correct. A speech-language pathologist can perform an in-depth assessment of the client's swallowing and communication abilities and teach the client strategies for eating safely and performing other ADLs.

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27.

A nurse manager is conducting a disaster-preparedness drill and observes nurses applying triage tags to clerical staff who are posing as injured clients. The manager should expect the nurses to apply which of the following tags to a client who has an ankle sprain? 

Red

Red tags identify a client who requires immediate intervention due to an immediate threat to life, but whose chances of survival are good. Clients who have shock or airway obstruction receive red tags.

Yellow

Yellow tags identify a client who has serious injuries that require intervention within 2 hr, such as open fractures and major wounds.

Green

MY ANSWER

Green tags identify a client who has minor injuries that can wait for treatment, such as sprains, strains, closed fractures, and abrasions.

Black

Black tags identify a client who is dying, such as those who have severe head trauma, extremely extensive and severe burns, or clients who have already died.

28.

A nurse is assisting a client who is scheduled to undergo a hysterectomy after signing an informed consent form. The client states, 'Signing this form makes me nervous.' Which of the following responses should the nurse make?

'Would you like to speak with the provider again?' 

MY ANSWER

When witnessing informed consent, the nurse is responsible for notifying the provider if the client has questions or appears not to understand any of the information about the surgery.

'Have you explored alternatives to surgery?'

The nurse should not give the client any information that might contradict the information the provider gave. It is the provider's responsibility, not the nurse's, to discuss alternative choices with the client.

'Would you like one of your family members to sign the form?'

Partners or other family members cannot legally sign an informed consent form unless there is an approved guardianship or conservatorship, or the client's durable power of attorney for health care document has designated them to act when the client cannot.

'Would you like me to tell you how the provider will perform the procedure?'

When witnessing informed consent, the nurse is not responsible for explaining the procedure the provider will perform. That is the provider's responsibility.

29.

A nurse is planning care after receiving report for four clients. Which of the following clients should the nurse plan to assess first?

A client who has a BP of 118/74 mm Hg and is receiving treatment for hypertension

A blood pressure of 118/74 mm Hg is nonurgent for a client who is receiving treatment for hypertension because this finding is within the expected reference range of less than 120 systolic and less than 80 diastolic. Therefore, the nurse should assess another client first.

A client who has diabetes mellitus and a fasting blood glucose of 96 mg/dL

A fasting blood glucose of 96 mg/dL is nonurgent for a client who has diabetes mellitus because this finding is within the expected reference range of 70 to 110 mg/dL. Therefore, the nurse should assess another client first.

A client who is 2 days postoperative and has a urinary output of 500 mL/24 hr 

MY ANSWER

When using the urgent vs. nonurgent approach to client care, the nurse should immediately assess a client who is 2 days postoperative and has a urinary output of 500 mL/24 hr. This indicates an average urine output of about 20 mL/hr, which is less than the expected reference range of 30 mL/hr. This finding can indicate a fluid volume deficit, impaired kidney function, or impaired bladder tone which requires immediate assessment and intervention by the nurse.

A client who has a heart rate of 68/min and is receiving IV fluids 

A heart rate of 68/min is nonurgent for a client who is receiving IV fluids because this finding is within the expected reference range of 60 to 100/min. Therefore, the nurse should assess another client first.

30.A nurse suspects a client is developing opioid use disorder and reduces the client's dosage of pain medication by 50% without a prescription from the provider. The nurse checks on the client 1 hr later and sees the client sitting up in a chair. The client tells the nurse, 'I am in too much pain to reach the nurse call button.' The nurse is liable for which of the following legal violations?

Gross negligence

MY ANSWER

Gross negligence is an extreme breach of care with an intentional, reckless disregard of consequences. The nurse's actions were intentional and reckless, in opposition to the provider's prescription, and placed the client at risk for pain and injury.

Libel

Libel is a false written statement about a client's status that can result in injury. If the nurse documents that the client has a substance use disorder without any evidence to support that allegation, that written statement is libelous.

Battery

Battery refers to harmful or offensive touching without consent. There is no indication that the nurse touched the client in an inappropriate or harmful manner.

False imprisonment

False imprisonment is the unlawful, intentional confinement of a person within fixed boundaries. Although it can be difficult for a client who is in intense pain to rise from sitting or summon help, the nurse did not unlawfully confine the client to the chair or the room.

31.

A nurse is performing morning rounds for a client and finds the client's bedtime medications sitting at the bedside in a medication cup. Which of the following actions should the nurse take?

Contact the charge nurse to complete an incident report.

The person who discovers the incident should complete the incident report as soon as possible, even if it is not the same staff member who was involved in the incident.

Document the missed medication administration in the client's medical record.

It is the responsibility of the nurse to record the facts of the missed medication administration in the client's medical record. There should be enough information about the event so that treatment can be provided if needed.

Request that the nurse who prepared the bedtime medications complete a report.

MY ANSWER

It is the responsibility of the nurse who discovers an incident to report it and complete the incident report. The facility will investigate the incident.

Place a copy of an incident report in the client's medical record.

The nurse should not place a copy of the incident report in the client's medical record. This report is considered confidential communication and is used by the facility to alert the risk manager of the event.

32.

A nurse is prioritizing care for four clients. Which of the following clients is the nurse's priority? 

A client who is postoperative following a thyroidectomy and reports tingling around their mouth. 

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the client who is postoperative following a thyroidectomy and reports tingling around their mouth is the priority. The client could be experiencing hypocalcemia which can lead to tetany and respiratory distress. The nurse should assess the client for muscle twitching and respiratory distress and be prepared to administer IV calcium gluconate or calcium chloride.

A client who is postoperative following a total hip arthroplasty and reports a pain level of 6 on a pain scale of 0 to 10.

The nurse should identify that pain level of 6 on a 0 to 10 numeric pain scale is nonurgent because it is an expected finding for a client who is postoperative following a total hip arthroplasty. Therefore, there is another client that is the priority. The client might require repositioning, ice, or analgesics to promote comfort and relieve pain.

A client who is postoperative following a stapedectomy and reports vertigo.

The nurse should identify that vertigo is nonurgent because it an expected finding in a client following a stapedectomy due to irritation of the inner ear. Therefore, there is another action that is the priority.

A client who is postoperative following esophageal dilation and has green drainage from a nasogastric tube.

MY ANSWER

The nurse should identify that green-yellow nasogastric drainage is nonurgent because it an expected finding for a client who is postoperative following an esophageal dilation. Therefore, there is another client that is the priority.

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33.

A nurse at a long-term care facility discovers flames coming from a trash can in the day room. Which of the following actions should the nurse take first?

Close the doors leading to the area of the fire.

The nurse should close the doors leading to the area of the fire to prevent the fire from spreading. However, the nurse should take another action first. Using the RACE mnemonic, this is part of the third step, which is 'C' for 'confine.'

Activate the fire alarm to alert the fire department.

The nurse should activate the fire alarm to alert the fire department to ensure assistance with extinguishing the fire. However, the nurse should take another action first. Using the RACE mnemonic, this is part of the second step, which is 'A' for 'activate.'

Move the clients to an area of safety. 

MY ANSWER

The clients are at greatest risk for injury from flames and smoke inhalation. Therefore, the first action the nurse should take is to move the clients to an area of safety. Using the RACE mnemonic, this is part of the first step, which is 'R' for 'rescue.'

Use a fire extinguisher to put out the fire.

The nurse should use a fire extinguisher to put out the fire to prevent the fire from spreading. However, the nurse should take another action first. Using the RACE mnemonic, this is part of the last step, which is 'E' for 'extinguish.'

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FLAG

A charge nurse is observing a newly licensed nurse administer a unit of packed RBCs to a client. The charge nurse should identify the nurse has completed the procedure correctly when he completes the steps in which order? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 

3. Obtains the unit of packed RBCs for transfusion from the blood bank
4. Verifies the information on the blood bag with client's medical record and arm bracelet
5. Initiates an IV site with an 18-gauge IV catheter
6. Inserts the Y spike from the tubing into the blood bag
7. Infuses 0.9% sodium chloride solution

The first step the nurse should take when preparing to administer packed RBCs is to initiate an IV site with an 18- to 20-gauge IV catheter. Next, the nurse should infuse a solution of 0.9% sodium chloride to maintain IV catheter patency. Then the nurse should obtain the unit of packed RBCs for transfusion from the blood bank. Once the blood is obtained, the nurse should verify the information on the blood bag with the client's medical record and arm bracelet with another nurse. Finally, the nurse should insert the Y spike of the tubing used for blood product infusion into the blood bag.

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35.

A nurse encounters a client sitting on the floor in the hallway. The client says they slipped on some water on the floor and now their arm hurts. Which of the following actions should the nurse take first? 

Check the client for injuries.

MY ANSWER

The first action the nurse should take using the nursing process is to assess the client. The nurse should first check the client for injuries and make sure vital signs are stable. The nurse should also notify the provider of the client's fall and the assessment findings.

Notify the risk management department of the incident.

The nurse should complete an incident report and submit it to the risk manager to encourage proactive interventions to prevent further incidents of this type. However, there is another action the nurse should take first.

Call for assistance in helping the client back to bed.

Once the nurse determines that it is safe to move the client, the nurse should call for assistance to help get the client back to bed. However, there is another action the nurse should take first.

Call janitorial services to try to dry the floor and post warning signs.

The nurse should make sure the floor is as dry as possible and that there are warning signs if it is still wet so that no other clients or staff slip and fall. However, there is another action the nurse should take first.\

36.

A nurse manager is working with a team to resolve an ethical dilemma. Which of the following steps should the team take to make an informed decision? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 

• Identify and state the nature of the ethical dilemma. 
• List actions to take based on a list of alternatives.
• Decide to select one alternative.
• Communicate the justification for the decision.

The first step to resolve an ethical dilemma is for the nurse manager and team to identify and state the nature of the ethical dilemma in order to better understand a complex situation. The second step is to list actions to take based on a list of alternatives, such as reasonable actions to take, ethical principles to consider, assumptions to consider, and other possible ethical problems that the alternatives might produce. The third step is to decide to select one alternative to resolve the ethical dilemma after analyzing all the alternatives and considering the overall situation one last time. The final step is to communicate the justification for the decision by explaining the reason for resolution to the ethical issue.

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A nurse in an acute care facility is preparing to discharge an older adult client to home. Which of the following actions by the nurse demonstrates client advocacy?

Providing discharge instructions to the client about medications

The nurse should provide discharge instructions to the client regarding medications. However, this is an act of responsibility rather than a demonstration of client advocacy.

Documenting the client's emotional concerns regarding discharge

The nurse should document the client's emotional concerns regarding discharge. However, this is an act of responsibility rather than a demonstration of client advocacy.

Delegating assistive personnel (AP) to discharge the client in a wheelchair

The nurse should delegate an AP to discharge the client in a wheelchair. However, this is not a demonstration of client advocacy.

Contacting a social worker to assist the client with daily meal delivery services

MY ANSWER

The nurse is acting as a client advocate when the nurse contacts a social worker to assist the client with daily meal delivery services. Client advocacy involves contacting available resources on behalf of the client.

38.

A nurse manager is scheduling a meeting to address a conflict between staff members and a client's family. In the meeting, staff and family members will identify common goals and express their concerns. Which of the following conflict resolution strategies is the nurse manager implementing?

Competition

Conflict management by competition involves one person dominating others. It places winning above all else, including the costs of winning. It might be necessary in situations that involve unpopular or critical decisions, or when time does not permit for more cooperative techniques.

Collaboration

MY ANSWER

Collaboration involves both parties agreeing to work towards a common goal rather than individual goals to find a mutually satisfying solution to the conflict. The goal becomes what is best overall, rather than what each individual wants or thinks is best.

Accommodation

Accommodation is a passive way of dealing with conflict by giving false reassurances instead of dealing with the issue. It can preserve harmony when one person has a vested interest in an issue that is unimportant to the other party.

Smoothing

Smoothing involves complimenting the opponent, downplaying differences, and focusing on minor issues of agreement as though no real disagreement exists. This technique is ineffective for major conflicts. Bottom of Form

39.

A nurse is admitting a client who has heart failure and speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client using an interpreter?

Enhance understanding by using metaphors. 

Metaphors vary across cultures and can create confusion when communicating with a client.

Observe the client's nonverbal expressions.

MY ANSWER

The nurse should observe nonverbal expressions while the client is communicating with the interpreter. Body language and nonverbal expressions can assist the nurse to determine the client's understanding of the information.

Address the interpreter when asking questions.

The nurse should address the client, rather than the interpreter, when communicating. This indicates that the nurse acknowledges the client.

Speak words clearly by increasing vocal volume.

The nurse should speak clearly at a normal volume to enhance understanding and avoid offending the client. Bottom of Form

40. A nurse is providing teaching for a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

'I need to choose a family member to be my health care proxy.'

The client can designate any competent person to be a health care proxy. A health care proxy does not have to be a family member.

'My family member or a friend will use my living will for health care decisions when I am ill.'

The client's living will authorizes a designated health care proxy or the client's provider to use the living will for health care decisions when the client is no longer able to make decisions regarding treatment.

'I am unable to change my living will after I have signed it.'

The client can change a living will at any time, even after signing it.

'My health care proxy will make my health care decisions when I am no longer able.' 

MY ANSWER

The nurse should identify that the health care proxy can make health care decisions for the client if the client is no longer able to make decisions regarding treatment. The client should discuss her health care wishes with the health care proxy while she is able.

41. A nurse is planning for the discharge of a client who has advanced lung cancer. The client's partner tells the nurse that she plans to manage the client's care at home but she is concerned about leaving the client alone to attend to personal errands. Which of the following services should the nurse suggest?

Assisted living facility

Assisted living facilities provide assistance to clients who remain somewhat independent and live within the facility. The nurse should not suggest this service because the client's partner plans to provide care at home.

Social services

Social workers assist clients with financial problems, living accommodations, and some legal issues. It is not their responsibility to arrange direct caregiving. The nurse can make a direct service referral for the client without the assistance of a social worker.

Spiritual support person

A spiritual support person can provide religious or spiritual support, but the nurse should first determine the client's willingness for this type of interaction.

Respite care

MY ANSWER

Respite care services provide time away from caregiving responsibilities to attend to errands, needs, or social activities. An alternative caregiver, provided by respite care services, can care for the client temporarily at home. This makes it possible for a long-term caregiver or partner to step away from providing care for the client while still knowing that the client will receive the necessary care.Bottom of Form

42. A nurse in an emergency department is assessing an adult client from a long-term care facility who has a developmental disability. The nurse observes bruises in various stages of healing. The client denies any abuse and tells the nurse not to report the findings. Which of the following actions should the nurse take?

Respect the client's wishes.

The nurse is obligated to communicate unexpected findings to the health care team. Guidelines for reporting abuse of vulnerable populations vary from state to state. When the nurse suspects abuse, they must follow the state's mandates for reporting.

Document the findings for the provider.

MY ANSWER

The nurse should always document factual assessment findings in the client's medical record and notify the provider of unexpected findings to ensure the client receives the required treatment.

Share the findings with a close family member of the client.

Revealing medical information to a family member not only breaches HIPAA privacy rules, but it also might place the client at an increased risk for abuse.

Report the suspected abuse to the client's long-term care facility.

Reporting suspected abuse to the long-term care facility is inadvisable, because the nurse should ensure confidentiality and protect the client from retaliation. The client's abuse may have originated in that facility and might place the client at an increased risk for future abuse after the nurse reports it.

43.A nurse manager calls a staff nurse to come in and work due to staffing shortages on several units. The staff nurse is at home and has influenza. Which of the following actions by the staff nurse demonstrates the ethical principle of fidelity?

Report to work as requested.

The staff nurse should not go to work while ill and should remain at home until they recover. Reporting to work can place clients and other staff members at risk for developing influenza.

Agree to work only until the supervisor can find a replacement.

The staff nurse should not go to work while ill and should remain at home until they recover. Even working for a short time, the nurse can expose other staff and clients to influenza, which is spread through respiratory secretions.

State that staff nurses do not have an obligation to work on days off.

Although staff nurses do not have an obligation to work on their days off, this does not demonstrate the principle of fidelity.

Decline because nurses should not work when ill. 

MY ANSWER

Fidelity means keeping one's promises or commitments. Although the staff nurse has a duty to client care, it is not in the best interest of the client or other staff members to have a nurse who is ill come to work. This can place clients and other staff members at risk for developing influenza, and the nurse has a duty to promote health and safety as a licensed professional.

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44.

A nurse is teaching a newly licensed nurse about do-not-resuscitate (DNR) orders. Which of the following information should the nurse include in the teaching?

The provider decides whether a client should have a DNR order.

The client, the client's family, and the health care team jointly make a decision regarding a DNR.

The provider will discontinue the client's medications after writing a DNR order.

The client can continue to receive routine medications and care regardless of the DNR status. The DNR status indicates the client does not wish to be resuscitated in the event of respiratory or cardiac arrest.

The client will need to sign an informed consent form for CPR if they do not have a DNR order.

Health care staff are obligated to provide CPR to any client who needs it and does not have a DNR.

The provider should periodically evaluate the DNR order.

MY ANSWER

The provider should periodically evaluate the DNR order and revise it if the client's condition changes.

45.A nurse manager is providing disciplinary action for a staff nurse who is claiming 1 hr of overtime every day for the past month to complete computer documentation. Which of the following actions should the nurse manager take first?

Suspend the nurse.

The nurse manager should suspend the nurse for a specified period of time if the behavior continues. However, evidence-based practice indicates that the nurse manager should take a different action first.

Prepare a written reprimand of the nurse.

The nurse manager should prepare a written reprimand if the behavior by the nurse continues. However, evidence-based practice indicates that the nurse manager should take a different action first.

Terminate the nurse's employment.

The nurse manager should terminate the nurse's employment if the behavior continues. However, evidence-based practice indicates that the nurse manager should take a different action first.

Speak with the nurse regarding the incident.

MY ANSWER

Evidence-based practice indicates the nurse manager should first provide a verbal warning to the nurse as the initial step of the progressive disciplinary process. This allows the nurse manager to meet with the nurse privately to address the behavior and explain why this conduct is unacceptable. If the remaining steps of the progressive disciple process become necessary, the nurse manager will give a written reprimand, then a suspension, and finally the nurse manager will terminate the nurse if the behavior does not change.

46.

A nurse is performing mass casualty triage of clients following a tornado. Which of the following clients should the nurse identify as a priority for transportation to the acute care facility?

A young adult client who is comatose due to severe head trauma

A client who has severe head trauma has a minimal chance of survival even with intervention. Therefore, the nurse should not recommend this client for first transport.

An older adult client who has a compound fracture of the right forearm

MY ANSWER

A client who has a forearm fracture does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should not recommend this client for first transport.

A middle-adult client who has a severed lower extremity

A client who has a traumatic amputation requires immediate intervention for survival. Therefore, when using the survival approach to client care, the nurse should give priority for transfer to this client.

A child who has multiple abrasions

A child who has multiple abrasions does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should not recommend this client for first transport.

47.

A nurse is developing a plan of care for a client who has chronic kidney disease. The client gives the nurse copies of his advance directives which state that he does not want to begin dialysis. Which of the following actions should the nurse include in the plan?

Document within the medical record that the client has advance directives in place. 

MY ANSWER

The Patient Self-Determination Act requires acute care facilities to have documentation in the medical record that a client has advance directives. The nurse should document the client's wishes for other health care workers who are caring for the client so that they understand the client's plan of care.

Place a do-not-resuscitate (DNR) bracelet on the client.

The nurse should only place a DNR bracelet on a client if the provider has discussed the implications of a DNR status with the client and has written a prescription for the DNR status.

Ask the client to sign an Against Medical Advice form.

A client should sign an Against Medical Advice (AMA) form if the client intends to leave the facility without the consent of the provider.

Ensure the client's family is aware of the treatment decisions within the advance directives.

It is the client's responsibility, rather than the nurse's responsibility, to ensure that the client's family is aware of the decisions within the advance directives. The nurse should also maintain client confidentiality.

48.

A charge nurse is assigning tasks for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Collect a urine sample for urinalysis.

MY ANSWER

The nurse should delegate the collection of a urine sample for urinalysis to an AP because it is within the range of function for an AP.

Provide dietary teaching for a client who has a new diagnosis of Crohn's disease.

Providing dietary teaching is not within the range of function for an AP.

Obtain vital signs for a client who has an unstable blood pressure. 

The AP can obtain vital signs for a client who is stable. However, obtaining and monitoring vital signs for a client who has an unstable blood pressure is not within the range of function for an AP.

Administer medications for a client who has a gastrostomy tube.

Administering medications through a gastrostomy tube is not within the range of function for an AP.

49.

A nurse is caring for a client who was involved in a motor vehicle crash with his partner. The client asks the nurse about his partner's condition. Which of the following actions should the nurse take?

Access the electronic health record (EHR) of his partner to get a status update for the client.

The nurse should not access the EHR of a client they are not caring for because the nurse has no need to know. This action is a breach of security and client confidentiality.

Ask the nurse caring for the partner to come and speak with the client.

The nurse caring for the client's partner has no authority to discuss the partner's condition with the client without permission from the partner.

Tell the client a staff member will check on the partner.

The nurse cannot ask a staff member who does not have a need to know to check on the client's partner to obtain information on the partner's condition.

Let the client know that he will be updated as soon as possible. 

MY ANSWER

The nurse should obtain permission from the client's partner to release health condition information to the client.Bottom of Form

50.

A nurse from an acute pediatric unit who has not cared for adult clients in more than 5 years is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take?

Attend a formal orientation training program before reassignment.

The nurse should request future cross-training to reduce risk and anxiety related to future floating assignments but does not have to have special training before assisting with client care. The nurse should request a brief orientation to the unit.

Negotiate specific tasks to perform with the nursing supervisor.

MY ANSWER

The nurse should negotiate with the nursing supervisor about specific tasks to perform in order to ensure the nurse is providing safe care at the nurse's level of training and competence.

Ask a coworker to take their place.

The nurse manager determines which staff nurses should float when there is a unit need. Therefore, the nurse should not ask a coworker to take their place.

Refuse to accept the assignment to float. 

The nurse should not refuse to accept the assignment to float. However, the nurse should communicate openly with the nurse manager on the unfamiliar unit about limitations and concerns. Licensure as a registered professional nurse does not restrict the nurse to a type of care that is age- or specialty-dependent. Bottom of Form

51.A nurse is assessing a client who is 4 hr postoperative following an open appendectomy. Which of the following manifestations should indicate to the nurse that the client requires a nasogastric tube with low intermittent suction?

Decreased oxygen saturation 

The nurse should identify that a decreased oxygen saturation might indicate the need for the client to deep breathe. If the client's oxygen saturation doesn't improve, the nurse might need to apply oxygen.

Abdominal distention 

MY ANSWER

The nurse should identify that the client's abdominal distention along with pain can be an indication of a postoperative ileus that requires gastric decompression by inserting a nasogastric tube along with low intermittent suction to relieve the pressure in the client's abdomen and remove blood or fluid that might be in the gastrointestinal tract. This will also provide comfort to the client.

Decreased bowel sounds

The nurse should identify that decreased bowel sounds is an expected finding following surgery. The nurse should monitor the client for an increase of bowel sounds.

Incisional pain

The nurse should identify that incisional pain is an expected finding following surgery. The nurse can administer pain medication or provide nonpharmacological measures, such as heat and cold therapy, to help relieve the client's pain.

52.

A nurse is developing a plan of care for a client who is immobile and at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan?

Apply moisturizing lotion to the client's skin after bathing. 

MY ANSWER

A client who has dry and irritated skin is at a greater risk for skin breakdown and the development of a pressure injury. The nurse should minimize dryness by applying moisturizing lotions while the client's skin is moist after bathing.

Massage the client's bony prominences twice per shift.

The nurse should avoid massaging bony prominences. Evidence-based practice does not support this intervention and vigorous massage can lead to deep tissue trauma.

Maintain the head of the client's bed at a 45° angle.

The nurse should elevate the head of the client's bed to no more than 30° when the client is in a lateral position. This will reduce the risk for injury occurring from friction and shearing forces.

Place the client in contact isolation.

The client who is at risk for developing a pressure injury does not require contact precautions. The nurse and personnel caring for the client should follow standard precautions to prevent infection and pathogen transmission.Bottom of Form

53.

A charge nurse is conducting an in-service on advocacy for a group of newly licensed nurses. Which of the following examples should the charge nurse include in the teaching as a demonstration of client advocacy? (Select all that apply.)

A nurse refuses to administer dialysis to a client who has a terminal diagnosis.

A nurse reports a procedure was completed incorrectly by another nurse to the charge nurse. 

A nurse refuses to use a multi-dose vial of medication for the same client.

A nurse arranges for an interpreter for a client who speaks a different language.

A nurse administers medication in applesauce after a client refuses the medication. 

MY ANSWER

A nurse refuses to administer dialysis to a client who has a terminal diagnosis is incorrect. The nurse should recognize that advocacy involves following the Nurses' Code of Ethics, which dictates that nurses are required to care for all persons, regardless of the nature of their health problem. Contacting the provider if the client refuses to receive dialysis would be an example of client advocacy.

A nurse reports a procedure was completed incorrectly by another nurse to the charge nurse is correct. The nurse should report improper completion of a procedure to the charge nurse and complete an incident report describing the incident. Reporting to the charge nurse is an act of client advocacy, which allows the charge nurse to further monitor the client's condition and prevent negative outcomes.

A nurse refuses to use a multi-dose vial of medication for the same client is incorrect. The nurse does not demonstrate client advocacy when refusing to use a multi-dose vial for a single client, because this action does not promote cost-effectiveness of client care.

A nurse arranges for an interpreter for a client who speaks a different language is correct. The nurse should demonstrate client advocacy by requesting an interpreter for a client who speaks a different language than the nurse. An interpreter will facilitate understanding of the teaching and allow the client to communicate their needs to the nurse.

A nurse administers medication in applesauce after a client refuses the medication is incorrect. The nurse should recognize that advocacy involves recognition of the rights of the client to refuse treatment, including medications. By administering a medication to the client who refused it, the nurse is failing to follow the Nurses' Code of Ethics and is not acting as a client advocate.

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54.

A nurse in an emergency department is admitting a 15-year-old client who is accompanied by her grandparent. The client requires an open reduction and internal fixation of several fractures. The nurse confirms that the client's parents are out of the country. Which of the following actions should the nurse take? 

Inform the provider to ask the grandparent to provide consent.

MY ANSWER

The nurse should inform the provider that the grandparent is the closest adult relative available for signing the informed consent. The closest adult relative can provide consent in an emergency situation when the client's parents or guardians are unavailable.

Obtain consent from the client.

The client, who is a minor, cannot legally sign an informed consent form for surgery unless the minor is emancipated (living on their own, lawfully married, or serving in the military).

Find out whether the client has a health care proxy.

A health care proxy is a document established by an adult client (age 18 or over) which designates an individual to make health care decisions on behalf of the client when they are incapacitated.

Proceed with the surgery via implied consent.

Implied consent is appropriate in an emergency when a client is unable to sign and there is no one available to give informed consent.

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55.

A nurse manager is planning the staff's annual performance appraisals. Which of the following locations should the nurse manager choose to conduct the appraisals?

A private office with the door closed 

MY ANSWER

The nurse manager should conduct each performance appraisal in a private office with the door closed. In some settings, first-line managers do not have their own private office and might share a space with other first-line managers. However, the nurse manager should still deliver the performance appraisal in a private setting and without interruption.

Near the nurses' station to be accessible to staff

The nurse manager should not conduct a performance appraisal near the nurses' station, because of the increased likelihood for interruptions. A busy environment is not conducive for the manager or the nurse to remain focused on the content of the appraisal.

A quiet location with a witness present

The nurse manager should conduct the performance appraisal in a quiet location, but not in a public place where others can overhear the discussion. The discussion between the nurse and the nurse manager is confidential and a witness is typically not necessary.

In a conference room sitting behind a large desk

The manager should conduct the performance appraisal in a private office with chairs arranged side-by-side to promote a mutually respectful atmosphere.

56. A nurse is planning interdisciplinary care for a client experiencing an exacerbation of myasthenia gravis. Which of the following information should the nurse plan to communicate to an occupational therapist?

The client requests help finding a support group. 

The nurse should communicate the client's request for help finding a support group to a case manager or social worker. These interprofessional team members can assist the client with finding community resources.

The client has difficulty grasping eating utensils.

MY ANSWER

An occupational therapist assists clients with fine motor skills, often related to performing ADLs. The nurse should report the client's difficulty grasping eating utensils so the occupational therapist can evaluate the client and provide adaptive utensils, if needed.

The client is experiencing dysarthria.

The nurse should communicate the client's dysarthria, or difficulty communicating, to a speech-language pathologist. The speech-language pathologist can assist the client to communicate and provide recommendations to improve speech.

The client has been too weak to ambulate since admission.

The nurse should communicate the client's weakness and inability to ambulate to a physical therapist. A physical therapist can determine the client's need for assistive devices that promote mobility while the client regains strength.

57.

A nurse manager is considering changing the policy for administering medications to clients on a unit. Which of the following actions should the nurse manager take first? 

Recognize individual efforts during the change process.

The nurse manager should recognize individual efforts during the change process to increase driving forces to promote the change. However, there is another action the nurse should take first.

Develop strategies to enhance acceptance of changes.

The nurse manager should develop strategies to enhance acceptance and improve understanding of the changes. However, there is another action the nurse should take first.

Create a task force to implement needed changes. 

The nurse manager should create a task force to implement needed changes and to promote an increased acceptance of the changes. However, there is another action the nurse should take first.

Determine the unit staff's perception of the need for change.

MY ANSWER

The first action the nurse should take when using the nursing process is assessment. By determining the unit staff's perception of the need for change, the nurse manager will be able to implement effective change.

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58

A charge nurse is following up on a task delegated to another nurse and discovers an error that could harm the client. Which of the following actions should the charge nurse take?

Take accountability for the nurse's mistake.

The charge nurse is not accountable for errors made by the nurse. However, the charge nurse is responsible for evaluating whether the nurse can perform the required actions appropriately.

Create an incident report and document it in the client's medical record.

The client's medical record should contain factual information documented by the nurse who provides care. It should not contain references to errors or incident reports.

Delegate the task to another nurse.

The charge nurse should continue to work with the original nurse to ensure safe and effective care is provided.

Implement interventions to ensure the client's safety.

MY ANSWER

The charge nurse is accountable for supervision, follow-up, and interventions to safeguard the client, as well as any corrective actions. After discovering a situation with potential for client harm, the charge nurse's first actions should be those that promote client safety and correct any harm done.Bottom of Form

59. A nurse is caring for a client who is 4 hr postoperative following an appendectomy. While reviewing the client's postoperative prescriptions, the nurse notes a medication dosage greater than twice the expected amount and notifies the provider for clarification. Which of the following ethical principles is the nurse demonstrating?

Autonomy

Autonomy is the right for the client to make one's own decisions and does not relate to clarifying a client's medication dosage with the provider.

Justice

Justice is the ethical principle that supports treating all clients fairly and does not relate to clarifying a client's medication dosage with the provider.

Veracity

Veracity is telling the truth and does not relate to clarifying a client's medication dosage with the provider.

Nonmaleficence

MY ANSWER

The ethical principle of nonmaleficence emphasizes that one should do no harm to clients. By clarifying the prescription with the provider, the nurse is ensuring that no harm can occur from administering an incorrect medication dosage to the client.

60.

A nurse in a long-term care facility is caring for a group of clients. The nurse should prioritize which of the following clients for an interdisciplinary care conference?

A client admitted 48 hr ago who has anorexia and a BMI of 23

A client who was admitted 48 hr ago and who has anorexia might benefit from an interdisciplinary care conference if anorexia persists. However, this finding is nonurgent because a BMI of 23 is an expected finding for a client who has anorexia. A BMI between 23 and 27 is classified as normal. Therefore, another client is the priority for an interdisciplinary care conference.

A client who has COPD and an oxygen saturation of 92%

A client who has COPD and an oxygen saturation of 92% might benefit from an interdisciplinary care conference to arrange for home oxygen. However, this finding is nonurgent because an oxygen saturation of 92% is an expected finding for a client who has COPD. Therefore, another client is the priority for an interdisciplinary care conference.

A client who is 1 week postoperative following a hip fracture

When using the urgent vs. nonurgent approach to client care, the nurse should identify that the client who is 1 week postoperative following a hip fracture is the priority for an interdisciplinary care conference to address physical therapy, occupational therapy, dietary consultation, and social services.

A client who has decreased mobility and reports constipation

MY ANSWER

A client who has decreased mobility and reports constipation might benefit from an interdisciplinary care conference to address nutrition, activity, and medications that can promote healthy bowel function. However, this finding is nonurgent because constipation is an expected finding for a client who has decreased mobility. Therefore, another client is the priority for an interdisciplinary care conference.