A nurse is planning care for several clients. Which of the following clients should be assigned to a nurse case manager.
A client who has a neurological deficits following a cerebrovascular accident (CVA)
A nurse is on a team that consists of a licensed practical nurse (LPN) and an assistive personnel (AP). The team is caring for an infant who requires application of several topical preparations. The application of which of the following prescriptions can
Zinc Oxide (Desitin) applied to rash in perianal region with each diaper change
On a very busy day, a nurse observes an office nurse taking a new client's health history while in the waiting room. What is the most appropriate action for the nurse to take?
Speak to the nurse immediately in private.
A nurse on a busy medical-surgical unit has several tasks that must be completed to get a preoperative client ready for the surgical suite. The nurse is supervising a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following t
Assist with placing the client onto the stretcher for transport to the surgical suite.
A nurse is caring for several clients. Which of the following situations reflects an appropriate suspensions of client rights?
A confused client who is recovering from a head injury and abdominal trauma has her hands placed in mitts to prevent her from disrupting her abdominal wound.
A 13-year-old female client tells the charge nurse in the pediatric unit that she does not want a male nurse assigned to care for her. Which of the following is the nurse's best response?
I'll change the assignment so a female nurse is caring for you today.
A nurse manager has displayed such behaviors as establishing staff nurse committees to address unit issues, instituting an open door policy for talking about concerns, and supporting the professional development of all staff. The nurse should understand t
democratic.
A nurse has noticed that one of the providers makes suggestive comments. Because these comments make the nurse uncomfortable, the nurse's first action should be to
inform the provider that the comments create an uncomfortable environment and request that they be stopped.
A unit manager is preparing to present a staff development session regarding brain death. Which of the following statements should the nurse include in the presentation regarding the criteria for determination of death for purposes of organ donation?
Death involves the complete and irreversible cessation of all function of the entire brain, including the brain stem.
A nurse from a hospital's float pool has been assigned to the nursing unit to cover a staff absence. The float nurse reports to the charge nurse and says "I have never worked in this unit before." The appropriate response by the charge nurse is
I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you.
A client who has undergone a coronary arterial bypass graft procedure has been assigned a case manager. When the case manager introduces herself, she should describe her role to the client as a nurse who will be
facilitating the use of cost effective care measures and ensuring a timely discharge.
A nurse is admitting a client who has a medical diagnosis of lower gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)?
Showing the client how to use the nurse call light
A nurse is planning to perform a negotiation to manage a conflict. The nurse recognizes the ultimate goal of the negotiation process is to
create a solution in which all parties are satisfied.
A visitor asks the nurse about the client in the next room who has metastatic cancer and cries out frequently. The visitor says "That person must have a terrible disease. What is the matter?" Which of the following is an appropriate response by the nurse?
That client is quite uncomfortable. Does the crying out bother you?
A nurse is a member of a hospital-wide committee that has developed new documentation forms to meet the Joint Commission's standards for health care institutions. The nurse should understand that the greatest barrier to successful implementation of these
staff resistance to learning new charting forms and standards.
A nurse makes several observations during the course of care on a unit. Which of the following observations should the nurse recognize exemplifies the ethical concept of paternalism?
A nurse practitioner withholding information from a dying client so as not to cause the client distress
A nurse suspects that a co-worker is coming to work under the influence of alcohol. Which of the following behaviors in the workplace should the nurse recognize are consistent with substance abuse? (Select all that apply.)
Extended lunch periods and breaks
Calling in sick frequently on Mondays or Fridays
Decrease in concern regarding personal appearance and grooming
Excessive use of cologne or mouthwash
Within the last 6 weeks, a full-time nurse has been absent from work six times, and various reasons have been cited. Since this is the first instance of a potential problem with the employee, the nurse manager decides to take a nonpunitively to the absent
Verbally remind the employee about the agency employment standards.
A client presents to a neighborhood health clinic frequently with reports of depression. The client, who is involved in an emotionally abusive marriage, feels trapped and does not know where to get help. Which of the following is the best nursing action?
Refer the client to a local organization that assists people who are in unhealthy relationships.
A newly licensed nurse is preparing to perform a procedure that she has not performed before on a client. What resource is appropriate for the nurse to consult?
The policy and procedure manual for the unit.
A charge nurse is providing orientation to a new staff nurse regarding the management of a team consisting of a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following instructions by the charge nurse regarding care of a gro
The accountability for a task is assumed by the person to whom it is delegated.
While caring for a client, a nurse notices that the client's call light cord is frayed. Which of the following actions should the nurse take?
Replace the call light and send the frayed one to the repair department.
A nurse is asked to act as a preceptor to a newly licensed nurse. In agreeing to this role, the nurse realizes that the newly licensed nurse will learn best if the preceptor
is co-assigned with the newly licensed nurse and acts as a role model in completing their assignment.
A nurse is involved in continuous quality improvement monitoring and is asked to identify key quality indicators for a surgical unit. Which of the following sources of data is significant for the nurse to include in the plan as a key indicator?
Nosocomial infection rate
A client with a history of severe multiple sclerosis (MS) has filled out a living will and has asked the nurse to witness it. Which of the following would be an appropriate response by the nurse?
I would be glad to witness your signature on the living will.
Some nurses working on a telemetry unit have identified the need for updating the cardiac monitoring system so that arrhythmia detection in clients can be increased. The nurse manager should realize this type of expenditure for equipment
will need to be addressed in the capital budget plan for the unit.
A nurse in a mental health clinic is interviewing a client who has a history of substance abuse. The client reports an experience from a previous voluntary hospitalization. The client says "I'll admit that I was rather anxious and hostile, but they wanted
Being threatened with the injectable medication
Immediately following the morning report, a nurse delegates several tasks to the assistive personnel (AP) on the team. Which of the following tasks should the nurse direct the AP to perform first?
Obtain the morning blood glucose fingersticks.
A nurse is planning care for a group of clients. Which of the following assignments is most appropriate for the nurse to plan?
Delegating the administration of an intermittent tube feeding to the licensed practical nurse (LPN)
A client's spouse wishes to be present when the client's organs are harvested in the surgical suite. The nurse believes this may be an ethical issue for which he does not have the answer. Which of the following is the first action that the nurse should ta
Review institutional policy to determine if this practice is allowed.
A nurse manager has received a mandate that the team nursing approach be implemented on his unit, with licensed practical nurses (LPNs) and assistive personnel (AP) hired on as additional staff. Which of the following actions by the nurse manager should h
Introduce the mandate and facilitate development of a taskforce to plan for implementation.
An older adult client is going to be discharged to a long term care facility. Which of the following nursing actions is most effective for promoting continuity of care?
Providing a written summary of the client's nursing plan of care to the long-term care facility
A nurse involved in a continuous quality improvement program on a unit is reviewing charting information for the time of first postoperative ambulation of clients who had abdominal surgery. The nurse should know that this data collection represents a qual
process.
A nurse observes a coworker performing a procedure improperly. Although no harm is done to the client, the nurse is concerned about the coworker's knowledge regarding the proper way to perform the procedure. The initial action the nurse should take is to
speak with the coworker privately.
A client is being transferred to the surgical suite for a procedure when the client suddenly exclaims, "I've changed my mind. I don't want to go through with this!" Which of the following is an appropriate response by the nurse?
Let me call your surgeon while you tell me about your concerns.
A client is returning home from a nursing care facility following rehabilitation for a cerebrovascular accident. The client now walks with a walker. The home care nurse rearranges the furniture, removes throw rugs, and arranges for grab bars to be install
Nonmaleficence
A nurse is designated as the new nurse manager on a busy oncology unit. Behaviors displayed by the nurse manager include keeping her office door closed when she is in the office, not offering to help resolve daily staffing issues, and not scheduling any s
Laissez-faire
A nurse is caring for a client who is hospitalized and asks to review his medical record. Which of the following is an appropriate response by the nurse?
You may view your chart under the guidance of the health team member designated by hospital policy.
A client who is postoperative has a hemoglobin of 8.0 g/dL. The nurse delegates the administration of a unit of packed red blood cells for this client to a nurse floating from a psychiatric unit. Which of the following nursing actions is appropriate for t
Decline to hang the blood.
A nurse working in a busy postsurgical unit is assigned to admit a new client. Although the nurse has been instructed in the use of a new bedside computer charting system, the nurse has never completed a computerized admission independently. None of the o
Complete the head-to-toe assessment while taking notes on paper, and orient the client to the new environment.
A nurse sees a confused client who is on bed rest attempting to crawl over the side rails. Which of the following actions should the nurse take to promote client safety?
Stay with the client and notify the supervising nurse.
A representative from a medical insurance company calls the hospital for information regarding a client who sustained a head injury. The representative tells the client's nurse that the results of the client's latest computerized axial tomography scan (CA
Decline to give the results of the CAT scan to the representative.
A nurse administrator's leadership and management skills are highly regarded by the staff. One reason the nurse administrator is so highly regarded is the because of his actualization of the concept of justice, which he enforces by
scheduling staff so that each person works two holidays a year.
A nurse who is precepting a newly licensed nurse is explaining the nurse's role in obtaining client consent for a diagnostic or surgical procedure. Which of the following information is appropriate for the nurse to include in the explanation?
The person who will perform the procedure is responsible for obtaining informed consent.
A nurse finds a client standing next to the bed with the side rails in the up position. The client's IV is pulled out and he is confused, does not have an identification bracelet on, and states, "I cannot remember my name." Which of the following actions
Assess the client for injury.
A teacher brings a child to the school nurse's office because the teacher has noticed multiple bruises on the child's trunk and extremities in the last few days. The child reports falling out of a tree. The nurse's assessment findings show patterns of bru
report the findings to local police and social service agencies.
After a disaster plan is put into effect, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged to home due to a local incident involving many child victims. Which of the following clients should the nurse place on the po
A preschooler who has asthma and has scattered wheezes that resolve with PRN use of albuterol (Proventil)
A school-age child who has a femur fracture in an external fixation device and whose pain is controlled with PRN oral codeine
A developmentally delay
A nurse enters a client's room and discovers that a small fire has started. Which of the following actions should the nurse take first?
Move the client out of the room.
When checking the IV line of a client who is receiving a medication that is a known vesicant, the nurse notes that the IV is puffy and has no blood return. Determining that the IV has infiltrated, the nurse discontinues the infusion, removes the IV cathet
Submit the variance report per institutional guidelines.
A nurse is preparing to introduce the concept of critical pathways to hospital administrators in an effort to enhance the quality of client care. Which of the following statements should the nurse use to describe the purpose of a critical pathway? "A crit
multidisciplinary tool that guides client care and bases outcomes on an externally imposed time line.