Critical Care HESI Practice Answered 100% Correctly, A+ guide Fall 2022/2023.

Critical Care HESI Practice Exam Bank 2022. - The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Wh ...

Critical Care HESI Practice Exam Bank 2022. - The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently - A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver - A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation - A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? a. Loss of skin integrity caused by the burns b. Potential infection as a result of the burn injury c. Inadequate gas exchange caused by smoke inhalation d. Decreased fluid volume because of the depth of the burns - During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? a. Hypokalemia and hyponatremia b. Hyperkalemia and hyponatremia c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia - A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? a. Normal sinus rhythm b. Sinus tachycardia c. Sinus bradycardia d. Sinus arrhythmia - The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity c. Physical mobility d. Urinary elimination - A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer - A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. Decreased rate of glomerular filtration b. Excessive blood loss through the burned tissues c. Plasma proteins moving out of the intravascular compartment d. Sodium retention occurring as a result of the aldosterone mechanism - The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? a. Azotemia b. Hypokalemia c. Metabolic alkalosis d. Respiratory alkalosis - A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. Equal b. Unrelated c. Inversely related d. Directly proportional - A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted. b. Dressings will be changed daily. c. Personal protective equipment will be worn by staff. d. Room temperature will be kept below 72° F (22.2° C). - A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities - A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice - A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? a. "Do you have chest pain?" b. "Are you feeling anxious?" c. "Do you have any palpitations?" d. "Are you feeling short of breath?" - During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? a. Stimulating crying b. Suctioning the airway c. Using an Ambu bag with oxygen support d. Placing the infant in the reverse Trendelenburg position - While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin and aspirin b. Slow the rate and monitor the vital signs c. Stop the transfusion and administer normal saline through new IV tubing d. Ask the client to further describe the feeling and rate the pain - A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future d. Beginning realization of implications for the future - A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b. Numbness c. Skin desquamation d. Generalized discomfort - Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown d. Colorless - A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? a. Level of consciousness and pupil size b. Characteristics of pain and blood pressure c. Quality of respirations and presence of pulses d. Observation of abdominal contusions and other wounds - Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? a. Red b. Black c. Green d. Yellow - A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? a. Use a consistent approach to care and encourage participation. b. Prepare equipment while doing the procedure and explain the treatment to the client. c. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. d. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. - Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia - A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? a. Provide low-sodium milk. b. Provide high-protein drinks. c. Provide foods that are low in potassium. d. Provide 10% more calories in the form of fats. - A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? a. 20 b. 25 c. 30 d. 36 - A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels - Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS) - The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag - On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? a. Prepare for blood transfusions. b. Notify the surgeon immediately. c. Make the client nothing by mouth (NPO). d. Administer the prescribed preoperative sedative. - A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? a. Become aware of their personal values b. Gain information related to their needs c. Make correct decisions related to their health d. Alter their value systems to make them more socially acceptable - An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? a. Shyness b. Cultural variation c. Symptom of depression d. Shame regarding treatment - Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? a. Get the client's full name and address. b. Call for assistance from the psychiatrist. c. Know some myths and facts about sexual assault. d. Be aware of any personal bias about sexual assault. - Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans - The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? a. The child is developing a conscience. b. The child is learning about gender roles. c. The child is developing a sense of security. d. The child is learning about the political process. - A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion. b. Discuss the case with coworkers. c. Notify the primary healthcare provider of the client's refusal of blood products. d. Explain to the client that they will die without the blood transfusion. - Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? a. Enjoyment of specific foods is inherited. b. There are familial influences on childhood eating habits. c. Childhood obesity is usually not a predictor of adult obesity. d. Children with obese parents are destined to become obese themselves. - After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? a. Increased cultural sensitivity b. Decreased cultural imposition c. Decreased cultural dissonance d. Increased cultural competence - A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? a. Contact an interpreter provided by the hospital. b. Contact the client's family member to translate for the client. c. Communicate with the client using Spanish phrases the nurse learned in a college course. d. Communicate with the client with the use of a hospital-approved Spanish dictionary. - During a routine checkup a patient reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the patient's weight and BMI at a healthy range, but the patient states, "I wish I were as thin as my co-workers." The patient is at risk for what culturally-bound condition? a. Neurasthenia b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios - The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain b. Check the pressure dressing for bleeding c. Assist the client to ambulate around his room d. Irrigate the client's nasogastric tube with sterile water - A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? a. Culture shock b. Social immaturity c. Experience of discrimination d. Lack of interest in school activities - A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? a. Assign articles about various cultures so that they can become more knowledgeable. b. Relocate the nurses to units where they will not have to care for clients from a variety of cultures. c. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. d. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work. - A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? a. Coin in the umbilicus b. Tight diaper over the umbilicus c. Binder that encircles the umbilicus d. Adhesive tape across the umbilicus - What should a nurse consider about the past experiences of clients who have immigrated to this country? a. It affects all of their inherited traits. b. There will be little impact on their lives today. c. It is important that their values be assessed first. d. How they will interact is permanently established. - Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler? a. Children have no concept of right or wrong to guide their behaviors. b. Children imitate the religious behaviors without comprehending any meaning. c. Children reason and question some of the established parental religious standards. d. Children have a reverence for religious matters and are able to articulate their faith. - A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative impact on people's health." - A resident in a nursing home recently immigrated to the United States (Canada) from Italy. How does the nurse plan to provide emotional support? a. By offering choices consistent with the client's heritage b. By assisting the client in adjusting to American culture c. By ensuring that the client understands American beliefs d. By correcting the client's misconceptions about appropriate health practices - A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? a. Ask the nursing supervisor to discuss this with the healthcare provider. b. Encourage the family to bring in special foods preferred in their culture. c. Order a high-protein milkshake as a between-meal snack to stimulate her appetite. d. Explain to the family that the dietitian plans nutritious meals that the client should eat. - Which internal variable influences health beliefs and practices? a. Family practices b. Cultural background c. Socioeconomic factors d. Intellectual background - A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? a. The patient is of Asian culture. b. The patient is of African culture. c. The patient is of North American culture. d. The patient is of Latin American culture. - As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? a. Setting of care b. Anxiety disorder c. Attitudes and beliefs d. Cultural and ethnic disparities - The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family - How can the lines of communication be improved in a healthcare organization during the process of delegation? a. By considering all aspects of client care b. By selecting experienced nursing assistants as delegatees c. By appreciating and valuing each other's cultural perspectives d. By selecting a delegatee having similar strengths as that of the delegator - During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a. Spiritual belief b. Family practices c. Emotional factors d. Cultural background - The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? a. Yin/Yang balance b. Biomedical belief c. Determinism belief d. Magicoreligious belief - A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? a. Cultural desire b. Cultural awareness c. Cultural knowledge d. Cultural encounters - A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver? a. The nurse provides therapeutic treatment to the client. b. The nurse teaches the client about signs of spiritual distress. c. The nurse communicates the wishes of the client to family members. d. The nurse collaborates with the agency chaplain to pursue the best treatment plan. a,b, - Which nursing interventions are examples of the nurse as a caregiver? (Select all that apply) a. Encouraging the client to exercise daily b. Setting goals for the client to reduce weight c. Arranging for the client to meet a spiritual advisor d. Evaluating the client's understanding of prescribed diet e. Demonstrating the procedure to self-administer insulin injection - An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? a. "The prevalence of hypertension is about equal for women of all races." b. "The higher-risk population is composed of African-American men and women." c. "The highest-risk population consists of older Caucasian-American men and women." d. "The prevalence of hypertension is greater for African-American men than for African-American women." - A nurse understands that when a client is a member of a different ethnic community it is important to do what? a. Ensure that the nurse's biases are understood by the family. b. Make plans to counteract the client's misconceptions about therapies. c. Offer a therapeutic regimen compatible with the lifestyle of the family. d. Recognize that the client's responses will be similar to other clients' responses. - Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson's Transpersonal Caring? a. Promoting transpersonal teaching-learning b. Promoting and expressing positive and negative feelings c. Developing a helping, trusting, human caring relationship d. Providing for a supportive, protective, and/or spiritual environment - The nurse leader states, "The people in rural America dress and act differently from those in urban centers." What concept describes this statement? a. Acculturation b. Ethnocentrism c. Cultural imposition d. Cultural marginality - A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism - The nurse is assessing a Latino-Caribbean patient who was brought to the hospital by family members. The family reports the patient started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? a. Bulimia nervosa b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios - A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? a. Seek the help of an official interpreter. b. Seek the help of the primary healthcare provider to assist the client. c. Seek help from the client's family friend who speaks the client's language. d. Seek help from the client's caregiver who speaks the same language as the client. - A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? a. Cohesiveness b. Educational level c. Cultural background d. Socioeconomic status - A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? a. They affect their inherited traits. b. They have little effect on their lives today. c. They are important in assessment of their values. d. They establish personal interactions throughout life. - When caring for a client who adheres to a kosher diet, which important thing should the nurse make sure to exclude from the client's meals? a. Pork and shellfish b. Blood-containing food c. All meat, fish, and poultry d. Animal and dairy products during Lent - A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? a. "Do you like living in this country?" b. "When did you come to this country?" c. "Is there a family member who can translate for you?" d. "Which family member do you prefer to receive information?" - A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario? a. Spiritual factors b. Emotional factors c. Developmental stage factors d. Intellectual background factor - A pregnant client states, "Abortion is banned in our community because it interferes with God's creative work." According to the nurse, which variable influences the client's health belief? a. Emotional factors b. Cultural background c. Socioeconomic factors d. Perception of functioning - A school nurse works with adolescents who recently immigrated to the U.S. and are adjusting to life in the public schools. What characteristics help the nurse differentiate students who are assimilating from students who are acculturating? a. Students who acculturate shun all aspects of their new culture. b. Students who assimilate are generally unhappy in their new culture. c. Students who acculturate tend to be more social in their new culture. d. Students who assimilate abandon all aspects of their original culture. - A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? a. Eating beef and veal is prohibited. b. Consumption of fish with scales is forbidden. c. Meat and milk at the same meal are forbidden. d. Consuming alcohol, coffee, and tea are prohibited. - The nurse starts a new job and recognizes that the patient population is very diverse. What action will help the nurse to provide culturally competent care? a. Read about all of the cultural groups in the local population. b. Treat all of the patients the same, regardless of their cultural background. c. Increase self-awareness of cultural identity, cultural knowledge, and potential biases. d. Attempt to remain culturally neutral while treating patients of a different culture. - Among which group of women are breast cancer death rates the lowest? a. Hawaiian b. Puerto Rican c. Asian American d. African American a,b,c, - When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities Hispanic older adults face? (Select all that apply). a. Value differences b. Language barrier c. Lack of health care facility d. Inadequate health insurance e. Poor diet and nutrition a,b,e - ANS) - What statements about culturally congruent care by the student nurse are correct? (Select all that apply). a. "It is the main goal of transcultural nursing." b. "It is provided through cultural competence." c. "It is provided in accordance with set criteria." d. "It is bound to the professional health care system." e. "It depends on the patterns and needs of an individual." - A patient with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the patient's behavior and attitude is most consistent with which cultural group? a. German culture b. Somalian culture c. Ukrainian culture d. More secular culture - A patient who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? a. The student expects the interpreter to act as the patient's advocate. b. The student expects the interpreter to have a health care background. c. The student maintains steady eye contact with the patient. d. The student talks only to the interpreter about the patient. - While talking with a 60-year-old patient, the nurse learns that the patient emigrated 15 years ago from China and likes to live independently away from the patient's grown children. The patient eats only Chinese foods at home. What should the nurse infer from these findings? a. The patient has undergone assimilation. b. The patient has undergone biculturalism. c. The patient has undergone acculturation. d. The patient has undergone enculturation. - Which instruction would be most beneficial for an aging African-American client with hypertension? a. "Check the pulse daily." b. "Have an annual urinalysis." c. "Record blood pressure weekly." d. "Visit an ophthalmologist monthly." - An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client. b. The nurse should proceed with the transfusion in order to save the client's life. c. The nurse should inform the primary healthcare provider and not give blood to the client. d. The nurse should explain to the family member that the client needs this transfusion. a,b, - What points should a nurse keep in mind when caring for a client who belongs to a different culture? (Select all that apply). a. The nurse should be aware of his or her own cultural values and behavior patterns. b. The nurse should focus on understanding the client's traditions, values, and beliefs. c. The nurse should understand that unique cultural perceptions exist regarding health practices. d. The nurse should know that every client strictly adheres to his or her cultural beliefs and traditions. e. The nurse should know that a client's cultural background does not influence the nurse-client relationship. - An elderly client states, "Disease occurs when supernatural elements enter the body." Which variable influences the client's health beliefs in this scenario? a. Spiritual factors b. Emotional factors c. Intellectual background d. Perception of functioning - In order to provide ideal therapeutic communication to patients, a health care facility provides interpreter services. Which statement regarding an interpreter is correct? a. Interpreters can be relatives or friends of the patient as well. b. The interpreter should be able to make literal, word-for-word translations. c. The interpreter should be able to interpret not only the language but also the culture. d. The interpreter should be available as long as the health care provider is caring for the patient. - What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness? a. Referring the husband to a psychotherapist for help in dealing with his anger b. Placing the couple in a couples' therapy group that addresses terminal illness c. Helping the couple express to each other their feelings about his terminal illness d. Encouraging the wife to verbalize her feelings to a therapist during individual therapy sessions - A patient who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? a. Immediately involve pastoral services while caring for the patient. b. Involve the family member in the patient's care instead of pastoral support. c. Listen to the patient's request for support then carry on with the clinical work. d. Falsely promise that pastoral services has been contacted and plan to see the patient. - A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? a. Restore the client's health. b. Promote the client's recovery. c. Relieve the client's discomfort. d. Support the client's significant others. - A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox and did not want to go to school but she insisted that the child go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? a. Grow in intensity and duration b. Progress to a psychiatric illness c. Be easier to understand and to accept d. Cause the mourner to experience a pathological grief reaction a,d,e - ANS) - A patient who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? (Select all that apply). a. Chemotherapy b. Repositioning c. Regular oral care d. Blood transfusion e. Radiation therapy - A patient with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the patient is terminally ill. What is the best nursing intervention in this situation? a. Suggest that the family members get a second opinion. b. Suggest that the family members continue to try different treatments. c. Encourage the family members to provide pallative care to the patient. d. Inform the family members that the disease is no longer curable and the patient will die shortly. b,d,e - ANS) - After reviewing a patient's reports, the primary healthcare provider suggests palliative care for the patient. Which conditions would qualify the patient for this type of care? (Select all that apply). a. Peptic ulcer b. Chronic renal failure c. Cognitive impairment d. Congestive heart failure e. Chronic obstructive lung disease - A terminally ill patient has died in the hospital and it is time to inform the patient's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family? a. Primary health care provider b. Pharmacist c. Social worker d. Occupational therapist - A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? a. Add a placebo to the morphine to appease the spouse. b. Discuss with the spouse the risk for morphine addiction. c. Assess the client's pain before increasing the dose of morphine. d. Check the client's heart rate before increasing the morphine to the next level. c,e - ANS) - What interventions should the nurse perform while caring for an actively dying patient? (Select all that apply). a. Admit the patient in hospice care. b. Perform aggressive laboratory tests. c. Provide patient and family reassurance. d. Keep the patient undisturbed for long time. e. Perform symptom management in the patient. - A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? a. Enhances the quality of the client's life b. Reduces the likelihood of a respiratory infection c. Prevents the malabsorption syndrome from occurring d. Cures the cachexia that results from bone cancer and chemotherapy 0.2 - ANS) - A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ____________ mL - The primary healthcare provider instructs the nurse to manage fluid replacement therapy in a patient with cancer. What type of care is the patient receiving? a. Palliative care b. Comfort care c. Supportive care d. End-of-life care - What should a nurse recommend to best help a client during the period immediately after a spouse's death? a. Crisis counseling b. Family counseling c. Marital counseling d. Bereavement counseling - A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? a. "What makes you think he doesn't love you?" b. "Avoidance is a defense. He needs your help to cope." c. "Do you think he's having difficulty dealing with your illness?" d. "You seem very upset. Tell me how your husband is avoiding you." a,b,e - ANS) - Which nursing interventions enhance comfort in an imminently dying patient in the hospital? (Select all that apply). a. Frequently repositioning the patient b. Maintaining oral hygiene in the patient c. Limiting frequent visits of the family members d. Measuring the vital signs of patient frequently e. Applying body lotion to the patient's skin daily - The grieving wife of a client who has just died says to the nurse, "We should've spent more time together. I always felt that the children's needs came first." The nurse recognizes that the wife is experiencing what? a. Displaced anger b. Shame for past behaviors c. Expected feelings of guilt d. Ambivalent feelings about her husband - A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse best support the client's spouse? a. Assist the couple to maintain open communication. b. Offer the couple a description of the disease process. c. Instruct the spouse about the action of the medications. d. Meet privately with the spouse to explore personal feelings. - A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision? a. The newborn has no rights. b. It is the same as euthanasia. c. It is illegal professional practice. d. The newborn is being allowed to die. - A 76-year-old widower is terminally ill. He is very quiet and is unwilling to have visitors. During the initial contact with this client, what should the nurse do? a. Assess what the client knows about death and the dying process. b. Avoid talking about his condition unless he initiates the discussion. c. Encourage him to accept phone calls from those who wish to visit with him. d. Explore the extent to which he understands his situation and what the information means to him. - A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? a. Bargaining b. Frustration c. Depression d. Rationalization - According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? a. Anger b. Denial c. Bargaining d. Depression - What childhood problem has legal as well as emotional aspects and cannot be ignored? a. School phobia b. Fear of animals c. Fear of monsters d. Sleep disturbances - A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? a. "A nurse should provide a personal point of view." b. "Negotiations should be held in formal settings only." c. "Negotiation takes place immediately after gathering information." d. "The group agrees to a statement of the problem during the negotiation process." - A nurse who promotes freedom of choice for clients in decision-making best supports which principle? a. Justice b. Autonomy c. Beneficence d. Paternalism - Which nursing action indicates that the nurse is actively listening to the client? a. The nurse states his or her own opinions when the client is speaking. b. The nurse refrains from telling his or her own story to the client. c. The nurse reads the client's health record during the conversation. d. The nurse interprets what the client is saying and reiterates in his or her own words. a, - What is true about psychosocial changes observed in adolescents? Select all that apply. a. "They search for personal identity." b. "They develop their own ethical systems." c. "They consider themselves invincible." d. "They think of their parents as materialistic." e. "They get emotionally dependent on their parents." - A nurse administers intravenous (IV) therapy to the wrong client. What possible legal complications might the nurse face in such situation? a. Assault b. Battery c. Malpractice d. False imprisonment - What is the professional nurse's legal responsibility regarding child abuse? a. Honor the request of the parents not to report the suspected abuse. b. Report any suspected abuse to local law enforcement authorities. c. Return the child to the legal parent even if he or she is suspected of abuse. d. Provide the parents with a copy of the child's medical record. - A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? a. Battery b. Invasion of privacy c. False imprisonment d. Defamation of character - What legal complications might a nurse face for using a restraint without a legal warrant on a client? a. The nurse may be charged with libel. b. The nurse may be charged with negligence. c. The nurse may be charged with malpractice. d. The nurse may be charged with false imprisonment. - A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what? a. Libel b. Negligence c. Breach of confidentiality d. Defamation of character - A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? a. Demonstration of a personal bias b. Problem solving based on assessment c. Determination of client acuity to set priorities d. Consideration of the complexity of client care - What stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? a. Social contract orientation b. Society-maintaining orientation c. Instrumental relativist orientation d. Universal ethical principle orientation - The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation? a. Educator b. Manager c. Advocate d. Administrator - Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? a. Confront her friend with her suspicions. b. Talk to the school nurse about her concerns. c. Inform the girl's mother about her daughter's behavior. d. Watch a while longer before doing anything that might ruin the friendship. - A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? a. Justice b. Veracity c. Autonomy d. Beneficence - The professional obligation of a nurse to assume responsibility for actions is referred to as what? a. Accountability b. Individuality c. Responsibility d. Bioethics - A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. What role does the nurse play here? a. Educator b. Manager c. Caregiver d. Advocate - A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do? a. Honor the client's decision and document the behavior and all interventions. b. Use an authoritarian approach to induce the client to take the prescribed medication. c. Call the primary healthcare provider and request that the client be discharged against medical advice. d. Start proceedings to have the client declared incompetent and seek a court order permitting medication. - Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? a. Right task b. Right person c. Right supervision d. Right communication - Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? a. Restraints can be used when less restrictive interventions are not successful. b. Restraints can be used when all other alternatives have been tried and exhausted. c. Restraints can be used only to ensure the physical safety of the resident or other residents. d. Restraints can be used anytime without a written order from the healthcare provider. - Which of the following legal defenses are the most important for a nurse to develop? a. Dedication b. Certification c. Assertiveness d. Accountability b, c, e - ANS) - A nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. a. When consent has been obtained from the spouse b. When consent has been given specifically by a court c. When self-consent has been granted by a court order d. When consent has been given by a grandparent e. When consent has been obtained from at least one parent of the minor - What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare? a. A proxy is a legal document that prohibits the purchase or sale of organs. b. A proxy is a legal document that ensures the client has the right to refuse medical treatment. c. A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client. d. A proxy is a legal document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition. - The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? a. Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. b. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. c. Maintain immobilization of a client's leg to prevent dislodging a skin graft. d. Keep an older adult client from falling out of bed following a surgical procedure. - The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility - How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? a. It is a willful act violating a client's rights. b. It is a civil wrong made against a person or property. c. It is an act that lacks intent but involves volitional action. d. It is an unintentional act that includes negligence and malpractice. - Which ethical principles govern a nurse's behavior when making difficult decisions about a patient's care at the point of care? a. Bioethics b. Metaethics c. Clinical ethics d. Research ethics - Which ethical principle is violated when the nurse forgets to give a painkiller to a patient as promised? a. Justice b. Fidelity c. Veracity d. Nonmaleficence - A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? a. Treat all patients equitably and fairly. b. Act in ways to prevent harm to patients. c. Tell the patient the truth about their health. d. Help the patients to make informed choices. - What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? a. The nurse should focus on doing no harm. b. The nurse should keep promises made to clients. c. The nurse should respect the autonomy of clients. d. The nurse should keep the best interests of the client in mind. - A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement? a. Adequate, because the preparations are routine and need no explanation b. Effective, because the client's anxieties would increase if she knew the danger involved c. Questionable, because the client has the right to know what treatment is being given and why d. Incorrect, because only the primary healthcare provider should offer assurances about management of care - What is the duty of a nurse while caring for a client? a. The nurse should determine the client's care preferences. b. The nurse should hide serious information from the family. c. The nurse should inform the family after taking the required steps. d. The nurse should instruct the family to keep the client from doing things himself or herself. - A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction? a. An ethical issue occurs if it is perplexing and if it is not easy to think logically or make a decision. b. An ethical issue occurs if it is not possible to resolve solely through a review of scientific data. c. An ethical issue occurs if the problem aims at the greatest good for the greatest number of people. d. An ethical issue occurs if the answer to the problem has a profound relevance for areas of human concern. - On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, and barely has basic needs attended. The client is the primary caregiver for the infant. What should the nurse do? a. Advise the purchase of appropriate toys designed for this age level. b. Inform the client that the child will be cognitively impaired if he is not stimulated. c. Explain the need for the family to hire a mother's helper for the home. d. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference. - A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? a. Libel b. Slander c. Negligence d. Invasion of privacy - The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to do what? a. Call the security guard. b. Tell the nurse manager to go home. c. Have the supervisor validate the observation. d. Offer the nurse manager a large cup of coffee. Offer the nurse manager a large cup of coffee. - A nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond? a. Answer the questions softly so other people will not hear. b. Decline to discuss the friend's medical condition. c. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead. d. To provide reassurance, tell the coworker of the friend's test results that are within normal limits. - An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? a. Interview the client without the presence of family members. b. Report the abuse to the appropriate state agency for investigation. c. Accept the adult child's explanation until more data can be collected. d. Refer the client's clinical record to the hospital ethics committee for review. - A nurse assisting in a research study calculates the risk-benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? a. Human dignity b. Human rights c. Beneficence d. Utilitarianism - A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? a. Allow the visitor to review the record; sponsors have access to privileged information. b. Ask the primary healthcare provider about granting permission to the sponsor. c. Do not allow the sponsor to review the record. d. Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors. - A registered nurse is teaching a nursing student about malpractice insurance. Which statement by the nursing student requires correction? a. "Malpractice insurance provides for a defense when a nurse is alleged to have committed professional negligence or medical malpractice." b. "Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted." c. "If both the employing institution and the nurse are sued, the nurse needs to notify his or her private insurance carrier of the lawsuit, even though the nurse has insurance through the hospital." d. "If both the hospital policy and the private policy are considered primary and the hospital loses as a result of the nurse's act, the hospital may sue the nurse's private insurer to recover its losses." - It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse's addiction should be taken as an initial intervention? a. Counseled by the staff psychiatrist b. Dismissed from the job immediately c. Referred to the employee assistance program d. Forced to promise to abstain from drugs in the future - A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? a. Counsel the nurse about the problem. b. Ignore the problem until it happens again. c.Notify the nurse manager about the problem. d. Resolve the problem by sending the nurse home. - A child admitted to the hospital is in need of a life-saving heart transplant surgery. However, the parents refuse to allow the surgery stating that such surgeries are against their belief system. The nurse in charge of the client recognizes the situation as an ethical dilemma. What first step should the nurse take in order to resolve the dilemma? a. Evaluate the outcome of the plan of action over time. b. Verbalize the problem and agree to a statement as a group. c. Examine his or her own values critically to formulate an opinion about the issue. d. Obtain information from the child, the parents, health care workers, and other sources. b, c, - In what instances can a minor give consent for himself or herself for medical treatment? Select all that apply. a. The minor can give consent for his or her siblings. b. The minor can give consent for any venereal disease. c. The minor can give consent if he or she is lawfully married. d. The minor can give consent for a drug or substance abuse. e. The minor can give consent for an abortion. - A mother calls the emergency department and speaks to a nurse. Her 16-year-old daughter has just been found in her bedroom cutting her wrists. The mother says, "They're just superficial cuts; the old ones have healed just fine." The mother states that the daughter has had three previous psychiatric admissions for suicide attempts and says that "this situation is pretty much like the other times. I'm not sure whether I should bring her in tonight or tell her primary healthcare provider about what happened at her next appointment, later this week." What is the best reply by the nurse? a. "You should call 911 now and let them know that your daughter has made a suicide attempt and needs help." b. "You should let your daughter's primary healthcare provider know about this occurrence in the morning and see whether the provider wants you to make an appointment for her tomorrow." c. "It sounds like you're very experienced with this situation. You can probably talk to her at home and see whether she'll tell you why she decided to cut herself." d. "Call her primary healthcare provider in the morning and let the provider know what has happened. Don't have any further conversations about suicide, because you don't want to give her any more ideas about hurting herself." a, c, - What information should the registered nurse provide when educating a nursing student about living wills? Select all that apply. a. Health care workers should always follow the directions of a client's living will. b. Living wills provide clinically specific instructions that help in dealing with unforeseen circumstances. c. Clients use living wills to declare any medical procedures they want or do not want when terminally ill. d. Living wills are written documents that direct the client's treatments in the event of a terminal illness or condition. e. Living wills allow authorized individuals to make medical decisions on behalf of the client if he or she is unable to do so. - A nurse manager in charge of a unit overhears two nurses in a hall filled with visitors discussing a client on the unit who has AIDS. What should be the nurse manager's initial action? a. Place an incident report in each nurse's personnel record. b. Note the situation and intervene if it happens again. c. Inform the nurse who is in the role of supervisor for the shift. d. Have a conference with the nurses and talk about the need for confidentiality. - A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? a. Malice b. Tort law c. Malpractice d. Case law - A nurse needs to obtain consent for the medical treatment of a child whose parent is a minor. What appropriate step should the nurse take to obtain consent? a. The nurse should ask the minor to give consent. b. The nurse should wait for the consent of the court. c. The nurse should ask any adult siblings of the minor to give consent. d. The nurse should ask a legal guardian of the minor to give consent. - A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? a. Ambivalent feelings are present and acknowledged. b. A sedative type of medication has been given recently. c. A complete history and physical has not been performed and recorded. d. A discussion of alternatives with two primary healthcare providers has not occurred. - The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? a. Justice b. Veracity c. Autonomy d. Beneficence - A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? a. Refuse to suture wounds b. Follow the primary healthcare provider's instructions c. Agree to suture wounds in the primary healthcare provider's presence d. Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association) - The nurse informs a client's family that the client is in pain and does not wish to proceed with chemotherapy. What is the role of the nurse in this situation? a. Manager b. Educator c. Caregiver d. Advocate - A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? a. "My doctor will know what to do." b. "My family can make the decisions for me." c. "If something happens to me, I would rather die." d. "If I have a heart attack, I do not want any medication." - While having a group discussion in an organization, one of the team members criticizes an idea of another team member. Which strategy should the leader apply to resolve the issue? a. Focus group b. Brainstorming c. Delphi technique d. Nominal group technique - A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? a. Have two nurses witness the client signing the operative consent form. b. Ensure that the primary healthcare provider and the psychiatrist sign for the surgery because it is an emergency procedure. c. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. d. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit. - An elderly adult with Parkinson's disease falls while going to the bathroom and gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? a. The nurse should document the incident in the occurrence report tool. b. The nurse should provide information in the medical record about the occurrence. c. The nurse should document in the client's medical report that an occurrence report has been filed. d. The nurse should document in the client's medical report that the primary healthcare provider has been contacted. - A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? a. Inform the client of the results. b. Ensure that the results are placed in the client's medical record. c. Notify the client's primary healthcare provider of the results. d. Obtain results of the other lab tests that were performed. - A client with a mental illness in the emergency unit needs to undergo an emergency surgery. What would be the nurse's first course of action to prevent any legal complications? a. Wait for a court order to intervene on the client's behalf. b. Obtain consent from a person legally authorized to give it on the client's behalf, if available. c. Obtain a court order to state that the client is incompetent to decide for himself or herself. d. Request that the primary healthcare provider start the procedure without the client's consent. - A nurse who lacks confidence in her performance in a new position is worried about an upcoming review with the nursing director. What type of power does the nursing director hold in this scenario? a. Expert power b. Position power c. Coercive power d. Referent power - The family of a client infected with human immunodeficiency virus (HIV) wants to see the results of the client's blood tests, unaware that the client is infected. A nurse obliges the family's request without waiting for the client's consent. What legal charge may be brought against the nurse? a. Slander b. Negligence c. Invasion of privacy d. Defamation of character - A parent objects to the child's getting vaccinated because she believes that vaccinations can cause autism. However, a nurse gives the child the vaccination injection against the wishes of the mother. What legal charge may be brought against the nurse? a.Assault b. Battery c. Invasion of privacy d. False imprisonment - A nurse notes that the primary healthcare provider has scheduled a surgery for an unconscious client. An informed consent has not yet been obtained. What course of action does the nurse expect to be taken to deal with the situation? a. The client's spouse will give informed consent for the surgery. b. The procedure will be postponed till the client is able to give consent. c. The surrogate decision maker designated by the client will give consent. d. The primary healthcare provider will perform the procedure without waiting for consent. - A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? a. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." b. "Informed consent should be obtained in all situations except during extraordinary circumstances." c. "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." d. "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice." - What should the nurse do initially when obtaining consent for surgery? a. Describe the risks involved in the surgery. b. Explain that obtaining the signature is routine for any surgery. c. Witness the client's signature, which the nurse's signature will document. d. Determine whether the client's knowledge level is sufficient to give consent. - An adult client with mobility problems wishes to become an organ donor. Which act allows the client to donate his or her organs? a. Mental Health Parity Act b. Uniform Anatomical Gift Act c. National Organ Transplant Act d. Americans with Disabilities Act a, b, - A nurse signs as a witness to informed consent provided by the client. What does the signature of the nurse imply? Select all that apply. a. That the client's signature is authentic b. That the client has given consent voluntarily c. That the client appears to be competent to give consent d. That the client cannot refuse treatment after its initiation e. That the client has received a proper explanation of procedures from the nurse - An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight and is wearing soiled and inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do? a. Discuss the situation with the adult child. b. Ask the client whether the adult child is neglectful. c. Avoid reporting the situation to prevent alienation of the adult child. d. Report the suspicion of neglect by the adult child to adult protective services. - A registered nurse is educating a nursing student about assault. What information should the registered nurse provide? a. "Assault refers to any action of intentional touching without consent." b. "A procedure performed without the consent of the client is considered assault." c. "Assault refers to any action that places a client in apprehension of harmful contact without consent." d. "Threatening a client before performing a medical procedure is not considered assault." - When might a nurse be charged with client abandonment? a. If a nurse refuses to accept an assignment b. If a nurse walks out when staffing is inadequate c. If a client suffers an injury due to the nurse's inattention d. If a nurse makes a written protest to the nursing administrators - A registered nurse is educating a nursing student about abortion-related issues. Which statement provided by the nursing student post-teaching needs correction? a. "If a woman is in her first trimester, she may end her pregnancy according to state regulations." b. "In the third trimester when the fetus becomes viable, the state's interest is to protect the fetus." c. "If the fetus is over 28 weeks old, the state requires viability tests before conducting abortions." d. "In the second trimester, the state enforces regulation regarding the person performing the abortion and the abortion facility." - A nurse leader is educating student nurses in helping clients to perform their difficult self-care activities. Which key idea from a Source of Power is this statement referring to? a. Position power b. Coercive power c. Referent power d. Information power - After teaching a family member how to administer subcutaneous enoxaparin sodium, how should a nurse evaluate the effectiveness of the training? a. Return demonstration on a manikin b. Verbalization of the side effects of the medication c. Observing the family member administering enoxaparin sodium to the client d. Correctly verbalizing all necessary steps in enoxaparin sodium administration - A client who is to be discharged from an inpatient mental health facility is referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral? a. Improving social skills b. Getting out of the house for a few hours daily c. Maintaining gains achieved during hospitalization d. Avoiding direct confrontation with the community - A nurse is preparing to care for a client who engages in ritualistic behavior. What is the most appropriate intervention to include in the plan of care? a. Redirecting the client's energy into activities to help others b. Teaching the client that the behavior is not serving a realistic purpose c. Administering antianxiety medications that block out the memory of internal fears d. Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety - A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care at home. What should the nurse instruct the client to do? a. Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed b. Avoid food, drink clear liquids, take a daily temperature, and stay in bed c. Eat as much as possible, increase fluid intake, and call the office again the next day d.Take the oral hypoglycemic pill, drink warm fluids, and check your blood sugar before meals and at bedtime - A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? a. Increase fluids. b. Increase fiber in the diet. c. Wash hands with soap and water. d. Wash hands with an alcohol-based hand sanitizer. a, b, c, e - ANS) - Which colors are often included in an organizational disaster plan for use during triage? Select all that apply. a. Red b. Black c. Green d. White e. Yellow - Which health care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? a. Medical unit nurse b. Police officer c. Critical care nurse d. Unlicensed assistive personnel - What should the nurse teach a client who is taking warfarin? a. Report episodes of spontaneous bleeding. b. Increase the dose with prolonged inactivity. c. Take antibiotics, if injured, to prevent infection. d. Eat a diet with an increased quantity of green vegetables. - During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? a. Suggest that an antiemetic be prescribed b. Change the feeding schedule to omit nights c. Request that the type of solution be changed d. Gather more data from the night nurse about the technique used - Which response by the nurse during a client interview is an example of back channeling? a. "All right, go on..." b. "What else is bothering you?" c. "Tell me what brought you here." d. "How would you rate your pain on a scale of 0 to 10?" - A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin? a. Chest pain b. Blurred vision c. Persistent hiccups d. Increased urinary output - A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? a. Tympany b. Borborygmi c Abdominal bruit d. Pleural friction rub - When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. When teaching when to call the primary healthcare provider, what statement made by the client shows that teaching was effective? a. "I should call the primary healthcare provider for dry hair and an intolerance to cold." b. "I should call the primary healthcare provider for muscle cramping and sluggishness." c. "I should call the primary healthcare provider for fatigue and an increased pulse rate." d. "I should call the primary healthcare provider for tachycardia and an increase in weight." - A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? a. Notifying the receiving unit of the transfer b. Having the client's records ready for the transfer c. Verifying that the family has been notified of the transfer d. Checking that a bag-valve mask is available during the transfer - A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? a. Arteriolar constriction occurs. b. The cardiac workload decreases. c. Contractility of the heart decreases. d. The parasympathetic nervous system is triggered. - Which hospital department plays a primary role in disaster preparedness? a. Medical department b. Surgical department c. Emergency department d. Mental health department - A client with hyperthyroidism is to receive methimazole. What instructions does the nurse provide? a. Initial improvement will take several weeks. b. There are few side effects associated with this drug. c. This medication may be taken at any time during the day. d. Large doses are used to quickly correct the functions of the thyroid. - A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do? a.Sit on the edge of the bed so they can hold the client upright. b. Slide to the floor so the client will not be injured as a result of a fall. c. Bend forward so that blood flow to the brain is increased. d. Lie down immediately so they can take the client's blood pressure. - A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for which complication? a. Hypotension b. Hypokalemia c. Hypernatremia d. Hyperglycemia - A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what? a. Electromyography b. Pyridostigmine test c. History of physical deterioration d. Edrophonium chloride test - Which method of delivering client care works well in disaster situations? a. Team nursing b. Primary nursing c. Functional nursing d. Total patient care nursing - A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? a. "I want to stay as pain-free as possible." b. "I am not good at remembering to take medications." c. "I should not have any problems in reducing my salt intake." d. "I wrote down my dietary information for future reference." - Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? a. Administering oxygen b. Using an incentive spirometer c. Having the client breathe into a paper bag d. Administering an IV containing bicarbonate ions - A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? a. Promote gluconeogenesis. b. Produce an antiinflammatory effect. c. Promote cell growth and bone union. d. Decrease pain medication requirements. - During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? a. Increased appetite b. Recent weight loss c. Feelings of warmth d. Fluttering in the chest - A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? a. "Is your job demanding or stressful most of the time?" b. "Do you participate in any strenuous sports activities on a regular basis?" c. "Does anyone in your family have a history of central nervous system problems?" d. "Were you aware of anything different or unusual just before your seizure began?" - Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel - A client is having a tonic-clonic seizure. Which is a priority nursing action? a. Elevating the head of the bed b. Restraining the client's arms and legs c. Placing a tongue blade in the client's mouth d. Taking measures to prevent injury - A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? a. No special precautions are required. b. Cover the infected site with a dressing. c. Drape the client with a covering labeled biohazardous. d. Place a surgical mask on the client. - Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? a. Instruct the client to position one arm on each shoulder of the nurses. b. Direct the client to extend the legs and remain still during the procedure. c. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. d. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. - Which description by the nurse is a correct explanation of delegation? a. The transfer of responsibility for the performance of an activity b. The person's responsibility and accountability for individual actions or omissions c. The active process of directing, guiding, and influencing the outcome of an individual d. The transfer of both the accountability and responsibility from one person to another 18 - ANS) - A healthcare provider prescribes lidocaine HCl, 1.5 mg per minute, for a client whose ECG tracing reveals multiple premature ventricular complexes (PVCs). The nurse adds 500 mg of lidocaine HCl to 100 mL of D5W. To administer the correct amount of medication, at what rate should the nurse set the intravenous (IV) infusion pump? Record your answer using a whole number. ________________ mL/hr - Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? a. Listening b. Spiritual caring c. Providing presence d. Relieving pain and suffering - A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention? a. "Maintain elevation of both legs." b. "Massage the legs when they are painful." c. "Apply a hot water bottle to the legs." d. "Check pulses in the legs regularly." - The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? a. X-ray reports b. Severity of pain c. Results of blood work d. Family caregiver interview - What is a goal for a client who has difficulty with verbal communication precipitated by psychologic barriers? a. The client will be free of injury. b. The client will demonstrate decreased acting-out behavior. c. The client will identify consequences of acting-out behavior. d. The client will interact with other people in the environment. - Which amount of time is appropriate for a nurse to spend triaging each patient during a mass casualty incident? a. Less than 10 seconds b. Less than 15 seconds c. Less than 30 seconds d. Less than 60 seconds - What is the role of a case manager in a healthcare organization? a. To delegate work on the unit suitably b. To follow up with the client after discharge c. To provide direct care for the client at the bedside d. To unite the strategic direction of the organization - Which process involves transferring responsibility to multiple players, usually with varying degrees of education and experience, while retaining the ultimate accountability for providing the client care? a. Leadership b. Delegation c. Supervision d. Assignment a, - The registered nurse (RN) is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the unlicensed assistive personnel (UAP) to provide quality care to the client? Select all that apply. a. Recording vital signs b. Assisting the client with bathing c. Administering oral medications d. Preparing the care plan for the client e. Administering intravenous antibiotics - A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? a. Trimming toenails so that they are short and rounded b. Checking bathwater temperature by putting the toes in first c. Using alcohol to rub hands, feet, legs, and arms at least two times a day d. Seeking professional treatment for any minor injuries to the extremities - Which step in the nursing process would involve promoting a safe environment for the client? a. Planning b. Diagnosis c. Assessment d. Implementation - A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? a. "Can you describe the pain?" b. "Where exactly do you feel the pain?" c. "Which activities make the pain worse?" d. "What other discomfort do you experience?" - In which role does the nurse oversee the budget of a specific nursing unit or agency? a. Nurse educator b. Nurse manager c. Nurse researcher d. Nurse practitioner - A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? a. Reward healthy behaviors. b. Explain the treatment plan. c. Identify various means of coping. d. Encourage participation in community meetings. - A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy? a. Client is able to self-administer pain-relieving drugs as necessary b. Amount of medication received is determined entirely by the client c. Amount of drug used for analgesia matches sleep-wake cycles d. Self-administration relieves the nurse of monitoring the client for pain relief - A client diagnosed with tuberculosis is taking isoniazid. To prevent a food and drug interaction, the nurse should advise the client to avoid which food? a. Hot dogs b. Red wine c. Sour cream d. Apple juice - A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? a. Apply the patch on a distal extremity. b. Remove a previous patch before applying the next one. c. Massage the area gently after applying the patch to the skin. d. Apply a warm compress to the site before attaching the patch. - When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? a. Elevate the head of the bed between 30 and 45 degrees. b. Decrease flow rate at night. c. Check for residual daily. d. Irrigate regularly with warm tap water. - A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? a. Renin causes a gradual decrease in arterial pressure. b. Lipid plaque formation occurs within the arterial vessels. c. Development of atheromas within the myocardium is characteristic. d. Mobilization of free fatty acid from adipose tissue contributes to plaque formation. - What should the nurse include when developing a plan of care for a client in the manic phase of bipolar disorder? a. Focusing the client's interest in reality b. Encouraging the client to talk as much as needed c. Persuading the client to complete any task that has been started d. Redirecting the client's excess energy to more constructive activities - A nurse is caring for a client attending a community-based health center and reviews the client's medical record. What should the nurse encourage the client to do? a. Wring a sponge repeatedly when washing dishes. b. Install faucets that require turning rather than pushing. c. Push with the palms rather than the fingers when rising from a chair. d. Actively use the hands for several hours each morning, sewing or knitting. - Which client care activity may a nurse safely delegate to an unlicensed health care worker? a. Assessing a client's mastectomy incision for signs of inflammation b. Assisting a client who is recovering from an abdominal hysterectomy to the bathroom c. Providing information about side effects to a client receiving chemotherapy for breast cancer d. Evaluating the effectiveness of an antiemetic that was administered to a client to relieve nausea - A nurse in the postpartum unit must complete several interventions before a client's discharge from the hospital. The nurse plans to delegate some of the tasks to an unlicensed health care worker. Which activity must be performed by the nurse? a. Taking the neonate's picture b. Placing the infant car seat in the car c. Comparing the identification bands of mother and infant d. Preparing the discharge packet and distributing them to parents - What should the associate nurse use to provide client care within the primary nursing delivery model? a. Plan of care b. Nurse's notes c. Physician's orders d. Direction from the charge nurse - Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? a. Apical heart rate b. Electrolyte levels c. Signs of bleeding d. Tissue compatibility - A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the primary healthcare provider? a. Start a 24-hour urine collection. b. Prepare for urinary catheterization. c. Teach the client how to perform perineal care. d. Obtain a urine specimen for culture and sensitivity. - A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? a. Falls b. Impaired cognition c. Imbalanced nutrition d. Impaired gas exchange - While organizing a community health care program for polio vaccinations, the registered nurse delegates the task of administering vaccines to the members of the health care team. Who among the health care team is most suitable to carry out the task? a. Technician b. Patient care associate c. Certified nursing aide d. Licensed practical nurse - Which team member acts as a liaison between the health care facility and the media? a. Triage officer b. Public information officer c. Medical command physician d. Hospital incident commander - Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed? a. "I need to have periodic tests of my blood for glucose." b. "I am glad that I only have to take the medication once a day." c. "I must take the medicine with meals while I have food in my stomach." d. "I should tell the doctor if I am overly restless or have trouble sleeping." - In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse's instructions? a. "I will sit in a chair for several hours every day." b. "I will inspect the incision for healing when I change the dressing." c. "I will check to see whether the staples have dissolved within a few days." d. "I will call the health care clinic if I see any clear drainage coming from the incision." - Which is essential for ensuring disaster readiness in a community? a. Trauma system b. State government c. Federal government d. Emergency response system a, - Which are examples of internal disasters that must be accounted for when formulating a disaster response plan? Select all that apply. a. Fire b. Hurricane c. Earthquake d. Power outage e. Act of terrorism - A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching? a. Take the iodine daily to increase the formation of thyroid hormone. b. Understand that medication will be temporary until the body adjusts to postsurgical activities. c. Take the propylthiouracil that is prescribed to stimulate the secretion of thyroid-stimulating hormone. d. Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone. - The nurse uses which principles of body mechanics when caring for immobilized clients? a. Bending at the waist to provide the power for lifting b. Placing the feet apart to increase the stability of the body c. Keeping the body straight when lifting to reduce pressure on the abdomen d. Relaxing the abdominal muscles while using the extremities to prevent strain - Which action involving client needs may a nurse delegate to an unlicensed health care worker? a. Assessing a newly admitted client's contraction pattern b. Discussing pain management options with a laboring client c. Providing ice chips to a primigravida in early labor per the primary healthcare provider's prescription d. Obtaining a sterile urine specimen for a suspected urinary tract infection - The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? a. Two b. Three c. Four d. Five - A nurse performs full range-of-motion exercises on a client's extremities. When putting an ankle through range-of-motion exercises, what must the nurse perform? a. Flexion, extension, and rotation b. Abduction, flexion, adduction, and extension c. Pronation, supination, rotation, and extension d. Dorsiflexion, plantar flexion, eversion, and inversion - During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that an intervention by an appropriate community resource is indicated. Where should the nurse direct the referral? a. Outpatient clinic b. Hospital pediatric unit c. Child Protective Services d. Bureau of the handicapped a, b, - Which threats, included in the term "NBC", lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. a. Nuclear b. Biologic c. Botulism d. Chemical e. Nipha virus - A client with achalasia is scheduled to have a bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for what complications related to esophageal perforation? a. Tachycardia and abdominal pain b. Faintness and feelings of fullness c. Diaphoresis and cardiac palpitations d. Increased blood pressure and urinary output - A nurse is providing postoperative care for a client one hour after an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication? a. Hypotension b. Hyperglycemia c. Sodium retention d. Potassium excretion - A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? a. "I will turn off clients' IVs that have infiltrated." b. "I will take clients' vital signs after their procedures are over." c. "I will use unit written materials to teach clients before surgery." d. "I will help by giving medications to clients who are slow in taking pills." - A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? a. Place the head and neck in alignment. b. Administer 1 gram mannitol intravenously (IV) as prescribed. c. Increase the ventilator's respiratory rate to 20 breaths/minute. d. Administer 100 mg of pentobarbital IV as prescribed. - According to the Model for Differentiated Nursing Practice, which entry-level nurse is most prepared for prioritization of client care? a. Licensed practical nurse b. Diploma registered nurse c. Associate's degree registered nurse d. Bachelor's degree registered nurse - Which component of delegation is retained while the delegator is delegating the client's care task to the nursing aide? a. Authority b. Supervision c. Responsibility d. Accountability - When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? a. Substernal chest pain b. Episodes of palpitation c. Severe shortness of breath d. Dizziness when standing up - A client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the healthcare provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client? a. "Do you eat foods high in vitamins?" b. "Do you have small children at home?" c. "How much caffeine do you consume each day?" d. "How many glasses of water do you drink per day?" - A client has a craniotomy for a meningioma. For which response should the nurse assess the client in the postanesthesia care unit? a. Dehydration b. Blurred vision c. Wound infection d. Narrowing pulse pressure - Which is a theme in the design of "Transforming Care at the Bedside"? a. Validity b. Reliability c. Cost-effectiveness d. Evidence-based practice - What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client? a. Monitoring clinical manifestations b. Collecting the data to be used in the assessment of the IV site c. Administering IV fluids and medications d. Evaluating the client for clinical manifestations - Which work is automatically increased for the delegator when there is a decrease in direct client care? a. Leadership b. Supervision c. Delegation d. Assignment - Who supervises unlicensed nursing personnel (UNPs) in providing care to the client? a. Charge nurse b. Nurse manager c. Registered nurse d. Patient care associate - The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations? a. Nursing aide b. Certified technician c. Patient care associate d. Licensed practical nurse c, e - ANS) - Which delegation actions may be performed by unlicensed nursing personnel while caring for a client? Select all that apply. a. Teaching the care plan to the client b. Infusing intravenous fluids into the client c. Asking the client to wash the hands before meals d. Instructing the client to take specific medications e. Instructing the client to wear footwear while walking a, c, - What are the three strategies that the nurse can perform while assisting other nurses in making delegation decisions? Select all that apply. a. Doing b. Telling c. Asking d. Offering e. Participating - A nurse is caring for a client who has just returned from the postanesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm? a. Performing range-of-motion exercises b. Humidifying the room air continuously c. Assessing for hoarseness every two hours d. Checking vital signs every two hours after they stabilize - Who is the designated delegator? a. Unit secretary b. Nurse manager c. Registered nurse d. Licensed practical nurse - Which statement is true regarding community emergency response teams (CERTs)? a. They provide first responder service to victims at the disaster site. b. They provide equipment to remain self-sufficient for 72 hours at the disaster site. c. They help healthcare professionals understand their responsibility in preparing for a disaster. d. They organize untrained volunteers to assist until professional services arrive at the disaster site. a, - Which employee should be competent in critical thinking, leadership, communication, and time management skills? Select all that apply. a. Charge nurse b. Student nurse c. Registered nurse d. Unlicensed personnel e. Licensed practical nurse - Who is mainly responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel (UAP) before delegating a task? a. Charge nurse b. Associate nurse c. Registered nurse d. Nursing manager - What type of trauma center would the nurse consider to be most appropriate for a client who survived an accidental fire and has multiple injuries? a. Level I b. Level II c. Level III d. Level IV - Which treatment for anthrax should be included in the biologic agent portion of a disaster plan for terrorist attacks? a. Antivirals b. Antitoxins c. Antibiotics d. Vaccinations - Who acts as a delegator in the absence of the registered nurse? a. Charge nurse b. Patient care associate c. Licensed practical nurse d. Unlicensed nursing personnel - Which healthcare team member would the nurse expect can be delegated with the task of administering oral medication to a client per the functional model? a. Registered nurse b. Patient care associate c. Licensed practical nurse d. Unlicensed assistive personnel a, - Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? Select all that apply. a. Paramedics b. Unlicensed assistive personnel c. Nurses appointed to a field team d. A physician who survives the incident e. Community response team members - Which healthcare team member is familiar with all the needs of any individual client? a. Orderlies b. Nursing aide c. Charge nurse d. Patient care associate - A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should place the client's affected extremity in which position? a. External rotation b. Slight hip flexion c. Moderate abduction d. Anatomic body alignment - A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? a. Strip the chest tube periodically. b. Administer the prescribed cough suppressant at the scheduled times. c. Empty and measure the drainage in the collection chamber each shift. d. Keep the drainage system lower than the level of the client's chest. - What is the main motto of the Hersey's 2006 model? a. Information decay b. Information salience c. Situational leadership d. Individual accountability - Which nursing professional has the maximum span of control? a. Nurse manager b. Registered nurse c. Patient care associate d. Licensed vocational nurse - The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? a. Care that supports physical functioning b. Care that supports homeostatic regulation c. Care that supports psychosocial functioning d. Care that provides immediate short-term help in physiological crises - What factors are most important for the nurse to consider when delegating responsibilities? a. Preferences of the clients and staff b. Physical layout of the unit and client rooms c. Staff member's level of education and expertise d. Client's diagnosis and length of time in the hospital - A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what? a. 2100 mL b. 4200 mL c. 6300 mL d. 8400 mL - When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? a. Obtain vital signs. b. Notify the healthcare provider. c. Reinsert the protruding organs using aseptic technique. d. Cover the wound with a sterile towel moistened with normal saline. - The nurse is caring for a client who is 1 day postoperative for a left hip fracture repair. During the assessment, which finding should the nurse assess further? a. Pain at the surgical site b. Small amount of serosanguinous drainage c. Decreased range of motion to the left extremity d. Sudden shortness of breath - The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? a. Prioritize psychosocial needs over physical needs. b. Use the Nursing Outcomes Classification (NOC) only. c. Use nursing knowledge to plan outcomes and disregard client and family desires. d. Set priorities and outcomes using the client's and family input. - To improve client care, the registered nurse (RN) has delegated tasks involved in assisting the client with activities of daily life (ADLs) to a certified nursing aide, and the administration of oral medications to the licensed practical nurse. Which member of the health care team would be accountable for the final client care? a. Registered nurse b. Chief nursing officer c. Licensed practical nurse d. Unlicensed nursing personnel - The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take? a. Clamp the tube. b. Consider this an expected event. c. Instill the tube with iced normal saline. d. Notify the surgeon immediately. c, - The nursing manager is preparing a schedule for delegating appropriate tasks to different health care team members. Which health care team member can be delegated the task of administering oral medications? Select all that apply. a. Certified technician b. Patient care associate c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed nursing personnel - The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? a. Planning b. Evaluation c. Assessment d. Implementation - The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? a. Crackles in lungs b. Supple skin turgor c. Urine output of 240 mL over 8 hours d. Increase in blood pressure from 110/76 to 124/68 mm Hg - A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? a. Curing the condition permanently b. Raising mucous secretions from the chest c. Limiting pulmonary secretions by decreasing fluid intake d. Convincing the client that the condition is emotionally based c, - Which events can result in adventitious crisis? Select all that apply. a. Divorce b. Marriage c. Terrorism d. Earthquake e. Mental illness - Who is responsible for establishing systems to monitor and verify the competency requirements related to delegation in an organization? a. Primary healthcare team b. Chief nursing officers (CNOs) c. American Nursing Association d. National Council of State Boards of Nursing (NCSBN) - A registered nurse is explaining the Quality and Safety Education for Nurses (QSEN) competencies to a nursing student. What information should the nurse provide about the competency teamwork and collaboration? a. "A nurse should be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making." b. "A nurse should be able to understand that the client is the source of control and full partner when providing compassionate and coordinated care." c. "A nurse should be able to implement improvement methods to design and test changes in order to improve the quality and safety of the healthcare system." d. "A nurse should be able to work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care." - Which component is the ability to perform duties in a specific role? a. Authority b. Responsibility c. Accountability d. Legal authority c, - Which of these clients can be provided care safely by unlicensed nursing personnel? Select all that apply. a. A client with pain b. A client who is upset c. A client who is stable d. A client who is recovering e. A client with suicidal intention - Which client's healthcare requirements cannot be delegated? a. Client A b. Client B c. Client C d. Client D - When does a delegator identify that the delegatee is less able to perform in a given situation? a. When the delegatee is upset b. When the delegatee is bored c. When the delegatee is anxious d. When the delegatee is knowledge deficient - A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility of acting as the team leader? a. Unit secretary b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel - When caring for a client with venous insufficiency, the nurse would implement which nursing measure? a. Apply abdominal girdle as needed. b. Remove compression stockings for client ambulation. c. Elevate the client's legs above heart level. d. Keep the upper extremities elevated. - Which statement best describes a fundamental aspect of the clinical nurse leader (CNL)? a. Schedules staff to cover work shifts b. Evaluates care for evidence-based approaches c. Serve as a liaison between team leaders and other care providers d. Meets with unlicensed assistive personnel (UAP) to review tasks - Which factor is known to threaten the nurse's ability to triage and prioritize client care accurately? a. A caring ethic b. A biased approach to care c. The shift that is being worked d. The specific number of years of job experience a, b, e - ANS) - The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Select all that apply. a. Documenting vital signs b. Documenting urine output c. Assessing the laboratory findings d. Administering diuretic intravenously e. Repositioning the client every one or two hours a, d, e - ANS) - Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply. a. Collaboration b. Care planning c. Communication d. Clinical judgment e. Cultural competency b, c, - What principal components are associated with a nurse's time management skill? Select all that apply. a. Autonomy b. Goal setting c. Priority setting d. Interruption control e. Right communication - A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? a. Begin active exercises. b. Make a referral to the physical therapist. c. Position the client to prevent contractures. d. Avoid moving the affected extremities unless necessary. - The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? a. Ensuring the client's skin integrity b. Reviewing the preoperative instructions c. Administering general anesthetic to the client d. Placing the client in the correct position on the operating table b, e - ANS) - A client with foot ulcers is admitted to the hospital. The nurse manager should delegate the task of maintaining hygiene to which staff members to maximize efficient use of human resources? . Select all that apply. a. Registered nurse (RN) b. Patient care associate (PCA) c. Licensed practical nurse (LPN) d. Licensed vocational nurse (LVN) e. Unlicensed nursing practitioner (UNP) - The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? a. Careful monitoring for crepitus b. Bed rest with range-of-motion exercises c. Coughing and deep breathing every hour d. Covering the chest tube site with a sterile dressing - Which nursing model includes a registered nurse (RN) paired with technical assistance? a. Team nursing model b. Co-primary nursing model c. Patient-focused care model d. Functional model of nursing - Who is most accountable for an initial assessment and the ongoing evaluation of client care? a. Client b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel - The registered nurse (RN) administers intravenous fluids to a client who was in a motorcycle accident. Which assessments made by the nurse would be appropriate based on the principle of right task of delegation? a. Environmental conditions b. Resources required for drug administration c. Institutional policies of drug administration d. Client's condition prior to drug administration a, d, e - ANS) - The registered nurse (RN) is caring for an older client who has been admitted to the hospital. The RN allocates several tasks to the unlicensed nursing personnel (UNP). In order to evaluate the understanding of the UNP, the RN asks the UNP to describe which tasks have been allocated. Which responses given by the UNP indicate effective understanding of the tasks? Select all that apply. a. "I must assist the client with oral care." b. "I must assess the client's health status." c. "I must administer intravenous drug in accordance with the schedule." d. "I must give a sponge bath to the client every morning." e. "I must record the blood pressure of the client at regular intervals." - A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? a. Administering analgesics b. Administering intravenous antibiotics c. Administering nerve block anesthesia d. Administering mouth wash for oral hygiene - Which team member is most accountable when delegating a task to the healthcare team? a. Certified technician b. Registered nurse (RN) c. Licensed practical nurse (LPN) d. Unlicensed assistive personnel (UAP) - A client has been receiving lithium for the past 2 weeks for the treatment of bipolar disorder, manic phase. What will the nurse include in the teaching plan for this client? a. A diuretic is necessary for anyone taking lithium. b. Lithium must be taken for the rest of the client's life. c. The blood level of lithium must be checked every month. d. A low-sodium diet must be followed while lithium is being taken. - Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? a. Local emergency management system b. State emergency management system c. Federal emergency management agency d. Hospital-level emergency management system - Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? a. Choking b. Redness c. Gagging d. Cyanosis - The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation? a. Planning b. Diagnosis c. Assessment d. Implementation - Which statement is true for attachment in the newborn? a. Attachment occurs for the first 28 days. b. Attachment begins in the first week of birth. c. Attachment is the overlapping of soft skull bones. d. Attachment is the interaction between parent and child. - A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? a. A young adult client with pneumonia b. An adolescent client with a fractured leg c. An older adult client who had a brain attack d. A middle-aged client who has cholecystitis - A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? a. "I would, but my back hurts today." b. "Okay. It will be my good deed for the day." c. "Of course. I want to do whatever I can for you." d. "I would like to, but it is not in my job description." - A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site 9 months ago. The site is healed, and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present? a. Notify the infection control officer. b. Inform the operating room of the MRSA. c. Obtain an order to culture the client's blood. d. Call the surgeon for an infectious disease consultation. - What entity outlined the principles of delegation for registered nurses? a. Nurse Practice Act b. Multilevel nursing model c. American Nurses Association (ANA) d. National Council of State Boards of Nursing (NCSBN) - The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? a. "I may experience a headache." b. "Confusion is a common adverse effect." c. "A slow pulse rate in an expected side effect." d. "Increased blood pressure readings may occur initially." - What should the community nurse teach about the risk of adolescent pregnancy? a. Risk for premature birth b. Risk for having a large baby c. Risk for chromosomal defects d. Risk for increased weight gain - Who is accountable for the ongoing evaluation of a client's care? a. Registered nurse (RN) b. Chief nursing officer (CNO) c. Licensed practical nurse (LPN) d. Unlicensed nursing personnel (UNP) - Who functions as a liaison between team leaders and other healthcare providers? a. Charge nurse b. Registered nurse c. Nursing manager d. Chief nursing officer b, c, - When should the nurse consider family members as the primary source of information? Select all that apply. a. The client is an elderly adult. b. The client is an infant or child. c. The client is brought in as an emergency. d. The client is critically ill and disoriented. e. The client visits the outpatient department. d, e - ANS) - Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply. a. Analyzing vital signs b. Maintaining oral hygiene c. Administering intravenous drugs d. Administering oral hypoglycemic agents e. Administering intramuscular medications - What is the status of the unit secretary as a member of the healthcare team, which is in the span of control of a registered nurse (RN)? a. Devoid of legal authority b. Answerable to the nurse manager c. Answerable to the registered nurse d. Devoid of performing non-medical tasks - Which statement best describes the navigator? a. A person who removes barriers to receiving health care b. A person who takes a client for a health care appointment c. A person who focuses on the long-term outcomes achieved by receiving needed care d. A person who ensures a specific plan of care is being followed to meet expected outcomes - The registered nurse considers the qualification of the unlicensed nursing personnel (UNP) before delegating a task. Which right of delegation is followed by the nurse? a. Task b. Person c. Direction d. Supervision - Which health care provider would best help a homeless client receive needed medication for a communicable disease? a. Navigator b. Case manager c. Primary nurse d. Unlicensed assistive personnel - The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? a. Nuclear family b. Extended family c. Single-parent family d. Skip-generation family - Which activity indicates improper follow-through on the part of the delegatee? a. Failure to report results b. Failure of effective communication c. Performing a task in the absence of a delegator d. Failure in following guidelines provided by a delegator - A client who sustained a leg fracture is prescribed intramuscular analgesic medication. Which healthcare professional can be safely delegated this task? a. Registered nurse (RN) b. Patient care associate (PCA) c. Licensed practical nurse (LPN) d. Unlicensed nursing practitioner (UNP) - In a health care setting, there are a limited number of unlicensed nursing personnel. Who would take up the responsibility of delegation in place of the registered nurse? a. Charge nurse b. Chief nursing officer c. Patient care associate d. Licensed practical nurse - Which healthcare professional would the nurse know is held accountable for the tasks performed by the patient care associate (PCA)? a. Registered nurse (RN) b. Licensed vocational nurse (LVN) c. Unlicensed assistive personnel (UAP) d. Unlicensed nursing practitioner (UNP) - Which characteristic indicates that nursing is a profession? a. The nurse is trained to perform specific tasks. b. The nurse is required to follow a code of ethics. c. The nurse is required to have a collection of specific skills. d. The nurse has limited autonomy in decision making and practice. - A nurse manager transfers the task of caring for a client who has undergone appendectomy to a registered nurse (RN). Which element of the healthcare system is the RN practicing? a. Delegation b. Leadership c. Supervision d. Assignment a, b, e - ANS) - Which are disadvantages to the functional system of care delivery? Select all that apply. a. Poor communication b. Fragmentation of care c. Efficiency with specific tasks d. Fixed number of registered nurses e. Changes in client status go unnoticed - Which statement best explains the focus of a therapeutic milieu management? a. Management of a therapeutic milieu is a nursing responsibility. b. The nurse-patient relationship is dependent upon therapeutic milieu management. c. Milieu management creates an environment that supports the client's therapeutic care. d. Creating a therapeutic milieu requires a proactive approach on the part of the nurse. - One component of a hospital disaster plan would include a workplace violence protection plan. Which unit in the hospital would be the priority for implementation and evaluation of this plan? a. Medical unit b. Surgical unit c. Emergency department d. Maternity department - Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? a. Pulse rate b. Blood pressure c. Respiratory rate d. Body temperature - Which personnel should the nurse state are responsible for deciding the number, acuity, and resources needed for clients during a disaster? a. Triage officer b. Community relations officer c. Medical command physician d. Hospital incident commander - Which activity performed by the licensed practical nurse (LPN) would be appropriate while caring for a client based on the principle of right task of delegation? a. Willing to perform the task b. Providing feedback to the delegator c. Performing the task based on institutional policies d. Following appropriate supervision while performing the task - Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? a. Covering the nose b. Protecting the eyes c. Decontaminating the skin d. Administering prophylactic antibiotics - Which factor is known to hinder the ability of the triage nurse to adequately prioritize care? a. Lack of clinical experience b. Lack of baccalaureate degree c. Compassion fatigue d. A team-based approach to care - While caring for a client with a permanent disability, the delegator delegated a task to the unlicensed assistive personnel (UAP). What type of care is provided to this client? a. Long-term care b. Restorative care c. First-access care d. Rehabilitative care - While caring for a client with arthritis, the delegator gave the task of administering medication intramuscularly to the client to another healthcare team member. Which healthcare team member is most appropriate to perform the task? a. Certified technician b. Registered nurse (RN) c. Patient care associate (PCA) d. Licensed practical nurse (LPN) - Which client's care is least likely to be delegated to unlicensed nursing personnel (UNP)? a. Client A b. Client B c. Client C d. Client D - A client with cirrhosis of the liver and ascites has been taking chlorothiazide, a thiazide diuretic. Why did the provider add spironolactone to the client's medication regimen? a. To stimulate sodium excretion b. To help prevent potassium loss c. To increase urine specific gravity d. To reduce arterial blood pressure b, c, d, e - ANS) - Which members of the health care team have dependent status under the registered nurse? Select all that apply. a. Unit secretary b. Certified nursing aide c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed nursing personnel - While caring for a client, the registered nurse (RN) needs the assistance of a licensed practical nurse (LPN). The RN feels that the LPN requires supervision as the LPN has previously only worked in a physician's office. Which action by the RN would help diminish any negative feelings the LPN might have about being supervised? a. Initiating a conversation about the limited skills of the LPN b. Appreciating the performance of the LPN when providing feedback c. Explaining the policies and procedures of the organization d. Initiating a conversation about the new role and functions of the LPN - The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client only lost 3 lbs (1.4 kg). How should the nurse respond? a. Assume that the client has been cheating on the diet. b. Increase the goal for next month to keep the client on track. c. Reevaluate the plan of care for appropriateness. d. Discontinue the plan of care because it did not work. - Given below in the table are the conditions of four different clients. Which client's care should be delegated to unlicensed assistive personnel (UAP) to achieve effective outcomes in the care? a.Client A b. Client B c. Client C d. Client D - A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? a. "She must not have the financial resources to leave her husband." b. "Most women try to leave about six times before they are successful." c. "There's nothing the staff can do; people are free to choose their own lives." d. "These women should be told how stupid they are to stay in that kind of situation." - Which health care professional is accountable for establishing systems to assess and communicate competency requirements related to delegation? a. Registered nurses b. Chief nursing officers c. Licensed practical nurses d. Unlicensed nursing personnel - Which among the Five Rights of Delegation is the cornerstone of delegation? a. "Right person" b. "Right supervision" c. "Right circumstance" d. "Right communication and direction" - Which certification course may be an elective for a nurse qualified to care for clients in a disaster-related emergency situation? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS) - A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare? a. Cool, moist towels b. Dry, sterile dressings c. Analgesic sunburn spray d. Vitamin A and D ointment - Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? a. Provides the greatest comfort b. Restores circulating blood volume c. Helps stop bleeding if any should occur d. Reduces the fluid trapped in the biliary ducts b, e - ANS) - A healthcare team is caring for a 68-year-old client with diabetes insipidus. Which task is most suitable to be delegated to licensed practical nurse (LPN) to provide effective client care? Select all that apply. a. Emptying the urinary drainage bag b. Monitoring urine output c. Feeding the client with food d. Administration of intravenous fluids e. Administering oral rehydration medication a, - The nurse manager is planning to assign an unlicensed healthcare worker to care for clients. What care can be delegated on a medical-surgical unit to an unlicensed healthcare worker? Select all that apply. a. Performing a bed bath for a client on bed rest b. Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) c Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered d. Assisting a client who has patient-controlled analgesia (PCA) to the bathroom e. Assessing the wound integrity of a client recovering from an abdominal laparotomy - A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? a. Sims b. Semi-Fowler c. Trendelenburg d. Dorsal recumbent a, - A client who underwent a nephrectomy develops pneumonia after being cared for by a registered nurse (RN) with some duties delegated to a cross-trained technician. Which individuals on the healthcare team may be responsible for the complication? Select all that apply. a. Registered nurse b. Patient care associate c. Cross-trained technician d. Licensed vocational nurse e. Unlicensed assistive personnel a, b, e - ANS) - Which statement is correct regarding delegation? Select all that apply. a. It involves transfer of authority. b. The delegator retains accountability for the outcome. c. The delegatee retains accountability for the outcome. d. It is the transfer of both responsibility and accountability. e. Principles of delegation outline what nurses need to know about the task. - During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important? a. The client should understand what will be discussed. b. The client will know that the nurse is trying to be helpful. c. The client needs to know what to expect from the relationship. d. The client will be able to be prepared for termination of the relationship. - A primary healthcare provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do? a. Advise the client to get more rest. b. Schedule the client for an appointment. c. Instruct the client to skip one dose daily. d. Tell the client to increase the medication. - A nurse leader, along with the team, is caring for a client who is scheduled for colonoscopy. Which delegated task requires the leader's supervision? a. Assisting the client with an enema b. Assisting the client with bathing c. Assisting the client with feeding d. Assisting the client with ambulating - A registered nurse is teaching a group of student nurses about concepts of triage in a mass casualty incident. Which statement of the student nurse indicates effective learning? a. "I will issue a black tag to class II, urgent clients." b. "I will issue a yellow tag to class I, emergent clients." c. "I will issue a green tag to class III, nonurgent clients." d. "I will issue a red tag to class IV, expected-to-die clients." - A nurse manager delegates the task of phlebotomy to the members of a healthcare team who are caring for a client with diabetes. Which individual on the team can be delegated to perform the task of phlebotomy? a. Registered nurse b. Cross-trained technician c. Licensed vocational nurse d. Unlicensed assistive personnel - Which healthcare team member is considered the priority person to insert an indwelling urinary catheter for a client who underwent a hysterectomy? a. Registered nurse b. Patient care associate c. Licensed practical nurse d. Unlicensed assistive personnel - A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity? a. Fidelity b. Autonomy c. Paternalism d. Beneficence - The nurse is assessing a young couple planning to start a family. What should the nurse tell the couple about the change that they will have to encounter in their family life-cycle? a. Develop intimate peer relationships b. Maintain own functions and interests c. Realign relationships with extended family d. Refocus on midlife material and career issues - A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? a. Cognitive response b. Emotional response c. Perceptual response d. Physical response - The registered nurse (RN) is caring for a pregnant client with malnutrition due to morning sickness. Which task can be safely performed by the licensed practical nurse (LPN) in this condition? a. Assessing hemoglobin levels b. Evaluating nutritional status c. Administering oral antiemetics d. Administering intravenous fluids - The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client? a. Certified technician b. Case manager c. Cross-trained technician d. Licensed vocational nurse (LVN) - The registered nurse (RN) is caring for a client who underwent surgery for a pituitary tumor. Which task can be delegated to unlicensed nursing personnel (UNP)? a. Teaching the client b. Monitoring vital signs c. Assessing laboratory reports d. Evaluating the status of the client - A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? a. Advising the client to join a support group immediately after discharge b. Assuring the family that staff members will take care of the client's needs c. Reminding the client to keep medical follow-up appointments after discharge d. Conducting a multidisciplinary staff conference early during the client's hospitalization - A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly? a. Provide constructive feedback. b. Engage in a verbal attack on the delegate. c. Express satisfaction with the LPN's execution of the task. d. Ignore the task for now but stop considering the LPN for further delegation. - A staff member is planning to start a new job but is worried about the impact it might have on future growth opportunities. The nurse leader is helping the staff member understand all the implications. Which ethical principle is the nurse manager as a leader following? a. Justice b. Veracity c. Paternalism d. Non-maleficence - A client requires emergency cardiac surgery. The leader nurse wants to make the client aware of the situation and wants the client to decide what should be done. Which ethical model does the leader nurse follow here? a. Autonomy model b. Paternalistic model c. Social justice model d. Patient-benefit model b, c, - What should a nurse manager as a leader do to provide a non-threatening and positive environment to the group members? Select all that apply. a. Ask indirect and close-ended questions b. Encourage group members to actively participate c. Create an environment conducive to solving problems d. Protect the members and their suggestions from attack e. Encourage the attempts of members to monopolize the discussion - The registered nurse (RN) is teaching a novice RN about delegating tasks to licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). Which statement made by the novice RN indicates a need for further teaching? a. "I will delegate the task of reinforcing client teaching to the LPN." b. "I will delegate the task of assisting the client with bathing to the LPN." c. "I will delegate the task of recording vital signs of the client to the UAP." d. "I will delegate the task of administering intramuscular injections to the LPN." - The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? a. Meet the clients' family. b. Read the clients' medical reports. c. Participate in the bedside rounds. d. Visit the clients and introduce self. - Which phase in the disaster management continuum does the nurse understand as including the attempt to limit a disaster's impact on human health and community function? a. Recovery b. Response c. Mitigation d. Preparedness - A client sustains a back injury after falling 20 feet (6 m). In which position should the nurse place the client? a. Lateral position with a pillow between the knees b. Any position that reduces pain and is comfortable c. Supine position while not allowing the spine to flex d. Sitting position with a pillow placed in the small of the back - A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving? a. Right task b. Right direction c. Right supervision d. Right circumstance - During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? a. Reinsert another tube immediately. b. Notify the healthcare provider at once. c. Keep calm because this is no immediate emergency. d. Quickly take action to prevent the tracheal stoma from closing. - Which element of the healthcare system is the registered nurse (RN) practicing when the delegator shares accountability with the RN? a. Delegation b. Leadership c. Supervision d. Assignment - A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider's writing. Who should the nurse ask for clarification of this prescription? a. Nurse practitioner b. House healthcare provider who is on call c. Healthcare provider who wrote the prescription d. Nurse manager familiar with the healthcare provider's writing - A client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do? a. Go back to regular activities. b. Enroll in an aftercare program. c. Call the unit whenever she is upset. d. Find a group that has similar problems. - A client with a fractured head of the right femur and osteoporosis is placed in Buck extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? a. Remove the weights from the traction every 2 hours to promote comfort. b. Turn the client from side to side every 2 hours to prevent pressure on the coccyx. c. Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction. d. Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion. - To reduce a fracture of the hip, a client is placed in Buck traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction? a. Add more weight to the traction. b. Elevate the head of the client's bed. c. Use a slight Trendelenburg position. d. Apply a chest restraint around the client. - The nurse uses evidence-based practice while providing nursing care to clients. What distinguishes research-based practice different from evidence-based practice? a. It uses knowledge based only on research studies. b. It is a problem-solving approach to clinical practice. c. It involves the conscientious use of current best practice. d. It involves clinical expertise and client preferences and values. - Which element creates an integrative process that fosters effective delegation decisions by the registered nurse? a. Ability b. Liability c. Stability d. Ethnicity a, b, - A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. a. Fever b. Tachypnea c. Hypertension d. Abdominal rigidity e. Increased bowel sounds - The registered nurse assigns a task to a licensed practical nurse (LPN) to check the blood pressure and temperature of a client. Which factor is transferred to the LPN for the performance of the task? a. Liability b. Authority c. Responsibility d. Accountability - The registered nurse oversees five unlicensed nursing personnel (UNP), and each UNP cares for five clients, so the registered nurse in effect has responsibility for five UNPs and 25 clients. What do these numbers of subordinate and clients indicate? a. Supervision b. Span of control c. Passive delegation d. Appropriate authority - While teaching a nursing student about delegation, the registered nurse instructs the student to determine whether the delegation process is appropriate to the situation before delegating a task. Which right of delegation is the registered nurse referring to? a. Task b. Person c. Supervision d. Circumstance - Which action should be the nurse's first priority for a client with major burns? a. Assessing airway patency b. Checking the client from head to toe c. Administering oxygen as needed d. Elevating the extremities if no fractures are noticed - The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation? a. Leadership b. Delegation c. Supervision d. Assignment c, e - ANS) - Which factors does the registered nurse consider in the decision to delegate process? Select all that apply. a. Evaluation b. Nursing judgment c. Predictability of outcomes d. Pervasive functions of assessment e. Complexity of the task to be performed - What nursing action will most help a client obtain maximum benefits after postural drainage? a. Administer oxygen as needed. b. Encourage coughing deeply. c. Place the client in a sitting position. d. Encourage the client to rest for a half hour. a, c, e - ANS) - A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. a. Taking routine vital signs b. Applying a sterile dressing c. Answering clients' call lights d. Administering saline infusions e. Changing linens on an occupied bed f. Assessing client responses to ambulation - A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? a. Localized seizures b. Skin desquamation c. Hyperactive reflexes d. Ascending weakness 640 - ANS) - A client who weighs 176 pounds (80 kg) is being immunosuppressed by daily maintenance doses of cyclosporine to prevent organ transplant rejection. The dose prescribed is 8 mg/kg each day. How many milligrams should the nurse plan to administer each day? Record your answer using a whole number. __________________ mg a, - The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Select all that apply. a. Pass the certification exam. b. Complete a master's degree in nursing. c. Learn how to prepare clinical pathways. d. Attend 30 hours of continuing education about the role. e. Pass the NCLEX-RN state board of nursing examination. - The registered nurse is caring for a client admitted to the hospital with chronic obstructive pulmonary disease. Which assessment by the registered nurse before delegating would help to determine the principle of "right person"? a. "Is the environment conducive for completing the task safely?" b. "Does the licensed practical nurse (LPN) know about polices of the institution?" c. "Can the nursing assistive personnel (NAP) evaluate the client's' condition appropriately?" d. "Does the nursing assistive personnel (NAP) have the knowledge and expertise to perform the task?" - The delegatee is performing a task and in the process loses confidence in what he or she is doing. Which delegator's action may have contributed to the delegatee's loss of confidence? a. Intervening when the delegatee is performing the task b. Providing feedback about the work performed c. Communicating with the delegatee about the work being performed d. Stating that the task should be completed by a specified time - A nurse, while assessing different survivors of a tornado, assigns a red tag to a client. What could be the casualty condition of the client? a. No treatment, expected to die b. Treatment can be delayed, minor injuries c. Requires emergent treatment, threat to life d. Require immediate treatment, major injuries - A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? a. Insert a urinary catheter. b. Initiate droplet precautions. c. Move the client to a private room. d. Use a high-efficiency particulate air (HEPA) respirator during care. - The registered nurse assesses if an unlicensed assistive personnel (UAP) new to the unit is capable of carrying out a task. Which principle of delegation does this illustrate? a. Right task b. Right person c. Right circumstance d. Right communication - A frantic parent calls stating their child has swallowed dish soap. What should the nurse advise? a. Call poison control. b. Induce vomiting immediately. c. Give syrup of ipecac, one tablespoon. d. Give activated charcoal, and expect black stools for 24 hours. - The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel? a. Administering antibiotics b. Assisting with personal hygiene c. Monitoring for signs and symptoms of infection d. Teaching the client and caregivers about how to avoid infection - The registered nurse delegates a task to the unlicensed assistive personnel (UAP). After the UAP starts the task, the registered nurse (RN) asks for feedback related to the task. Which right of delegation is the RN following? a. Task b. Supervision c. Circumstance d. Communication - A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care? a. Helping the client put on a wig before the client's visitors arrive b. Obtaining the client's consent for shaving the head c. Braiding the client's hair to keep it contained during surgery d. Instructing the client that with all cranial surgeries, the head is shaved after anesthesia has been administered - A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, what action does the nurse perform? a. Administer the medication after meals. b. Administer the medication on an empty stomach. c. Evaluate the client's psychological responses between medication doses. d. Evaluate the client's muscle strength every hour after the medication is given. - The registered nurse (RN) who delegates work to a newly hired licensed practical nurse (LPN) says, "Please tell me how you will go about performing this procedure, and I will share my expectations with you." Which behavior strategy of Hersey's model is being applied? a. Telling b. Selling c. Delegating d. Participating - An older adult client who is confused and often does not recognize family members is admitted to a nursing home. The client appears slovenly, often soiling clothing with feces and urine. How can the nurse best manage this problem? a. Toileting the client every 2 hours b. Placing the client in orientation therapy c. Supervising the client's bathroom activities closely d. Explaining to the client how offensive the behavior is to others - A block nurse is caring for an elderly couple in the neighborhood. What kind of service does block nursing offer to the elderly clients? a. Diagnostics b. Health screening c. Running errands d. Communicable disease control d, e - ANS) - A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? Select all that apply. a. Mobilizing the client b. Assessing the pulse rate c. Assessing the blood pressure d. Managing foot care of the client e. Maintaining oral hygiene of the client - The registered nurse is teaching a newly hired nurse about active delegation. Which statement made by the newly hired nurse indicates the need for further teaching? a. "I will evaluate the client's pain status." b. "I will assess the client's laboratory findings." c. "I will instruct the unlicensed assistive personnel (UAP) to wash the client." d. "I will instruct the licensed vocational nurse (LVN) to administer intravenous (IV) medications." - A client is to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is most important for the nurse to obtain? a. Infusion pump b. Tall intravenous (IV) pole c. Clamp taped at the bedside d. Infusion set delivering 60 drops/mL - In order to minimize the likelihood for error during intravenous administration of antibiotics, the legal authority advised the delegatee to wear a colored vest that says, "Do not disturb! Medication administration in process." Which delegatee is appropriate to follow the advice of legal authority? a. Nursing aide b. Registered nurse c. Patient care associate d. Licensed vocational nurse - Which client care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? a. Client A b. Client B c. Client C d. Client D - The registered nurse (RN) is caring for a client with severe diarrhea. Which task of the client care plan can be safely delegated to the unlicensed assistive personnel (UAP) by the registered nurse? a. Administration of oral antidiarrheal b. Administration of intravenous antibiotics c. Administration of oral replacement fluids d. Administration of intravenous antiemetics - A client underwent extraction of a tooth due to an underlying tumor one day ago. Which healthcare professional is appropriately involved in caring for the postoperative oral hygiene needs of this client? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Licensed vocational nurse (LVN) d. Unlicensed nursing practitioner (UNP) - Which activity performed by the registered nurse (RN) indicates effective supervision of the delegatee? a. Assigning the task to the delegatee b. Taking responsibility of the delegated task c. Guiding the delegatee while he or she is performing the task d. Understanding the nurse practice of the state b, e - ANS) - A client with hypoglycemia is admitted to the hospital. Which duties can the registered nurse (RN) safely delegate to the licensed practical nurse (LPN)? . Select all that apply. a. Intravenous fluid intervention b. Administering oral medications c. Monitoring the fluctuating vitals d. Analyzing the case history of the client e. Administering intramuscular medication - During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position? a.Supine b. Side-lying c. Low-Fowler d. Trendelenburg - A client requiring long-term ventilator management is discharged from the health care facility. Which health care setting should this client be referred to? a. Home care b. Rehabilitation c. Assisted living d. Intermediate care - The behavior of four nurses in different situations is given below. Which nurse exhibits a behavior that can be characterized as delegation according to Hersey's model? a. Nurse A b. Nurse B c. Nurse C d. Nurse D - The nurse is caring for a pregnant client with hypertension. Which client care tasks are most suitable to be delegated to the patient care associate (PCA)? a. Recording the vital signs b. Monitoring the blood pressure c. Administering intravenous fluids d. Administering antihypertensive medications - While caring for a client with diabetes, the registered nurse delegates the task of administering oral medications to the licensed practitioner nurse (LPN), but the LPN is reluctant to take the assignment. What should be the most appropriate response of the registered nurse in this situation? a. Evaluate the reason for the behavior. b. Engage more actively in the delegated task. c. Require the delegatee to complete the task. d. Report the LPN's reluctance to higher authorities. - Which right does the question, "Do staffing ratios demand the use of high-level delegation strategies?" indicate? a. The right task b. The right person c. The right supervision d. The right circumstance - A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client? a. Before the surgery b. During the convalescent phase c. On discharge from the hospital d. When it is time for a prosthesis a, b, - A registered nurse delegates the task of administering oral antibiotics for a client with diabetes. Which statements are true in this scenario? Select all that apply. a. The registered nurse (RN) is accountable for the delegatee's work. b. The licensed practical nurse (LPN) should report to the RN once the task is completed. c. The unlicensed nursing practitioner (UNP) can also be delegated the task of administering oral antibiotics. d. The licensed practical nurse (LPN) can be held responsible for any failure in administration of oral medication. e. The licensed practical nurse (LPN) can change the medication dosage according to the client's physiological needs in the absence of the RN. - The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? a. "Clients with decreased sensory perception of touch should be carefully monitored for infection." b. "Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts." c. "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." d. "Clients with decreased coordination should be instructed to hold handrails when ambulating." - The legal authority wants a record of the tasks performed by the delegatees and asks the delegatees to maintain a record of completed tasks. Which task is marked by the licensed practical nurse (LPN)? a.Task A b. Task B c. Task C d. Task D - After delegating a task to the unlicensed assistive personnel (UAP), the registered nurse (RN) provides clear and concise directions to the delegate, to whom she assigned the task. Which right of delegation is the RN following? a. Task b. Supervision c. Circumstance d. Communication - What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)? a. It offers 24-hour emergency care. b. It offers health care to acutely ill people. c. It provides temporary care for 96 hours or less. d. It provides the most expensive health care delivery. - Which facility has enabled rural hospitals to have increased access to specialist consultations? a. Medicare b. Medicaid c. Telemedicine d. Critical access hospital - A delegator is providing feedback to four delegatees. Which feedback may undermine a long-term working relationship? a. A b. B c. C d. D a, c, - What happens when a registered nurse does not trust other individuals in the healthcare organization? Select all that apply. a. Altered client care b. Appropriate delegation c. Compromised healthcare d. Limited career opportunity e. Efficient time management - Which strategy should be implemented by the registered nurse (RN) to achieve desirable client outcomes? a. Doing b. Asking c. Talking d. Offering - Which question does the registered nurse recognize as related to the right of circumstance when delegating? a. "Is the delegation appropriate to the situation?" b. "Is the task within the delegatee's scope of practice?" c. "Is the prospective delegate a willing and able employee?" d. "Is the delegator able to monitor and evaluate the client appropriately?" b, e - ANS) - The nurse delegates the tasks of caring for a postpartum client. During assessment, the nurse observes an infection in the client caused by lack of hygiene. Which member of the health care team is most likely responsible for the client's condition? Select all that apply. a. Physician b. Registered nurse c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed assistive personnel - Which activity performed by the registered nurse (RN) indicates following the "participating" leadership style in Hersey's model? a. Delegating the work to the delegatee b. Evaluating the ability of the delegatee c. Providing little guidance to the delegatee d. Establishing mutual expectations with the delegatee - A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? a. Discharge in am b. Blood glucose monitoring ac and bedtime c. Erythromycin 250 mg TIW d. Dalteparin 5000 international units Sub-Q BID - The registered nurse orders unlicensed nursing personnel (UNP) to check blood oxygen saturation levels every 6 hours and to report the results regularly. Which activity is the registered nurse performing in this situation? a. Active delegation b. Passive delegation c. Individual accountability d.Organizational accountability - While assigning a task, the registered nurse finds that one of the delegatees is not competent to hold the current position. Which strategy does the nurse follow for managing this issue during delegation? a. Attacking the delegate verbally b. Doing the task himself or herself c. Adjusting the quality of client care d. Lowering the expectations temporarily a, - Which factors should be assessed to determine the level of followers' readiness according to Hersey's model? Select all that apply. a. Ability b. Willingness c. Family history d. Work experience e. Educational qualifications - A newborn has just begun to breast-feed for the first time. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse best intervene at this time? a. Tell the client to use the other breast and continue breast-feeding b. Delay the feeding to allow more time for the infant to recover from the birthing process c. Contact the lactation consultant to help the client learn a more successful breast-feeding technique d. Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula - Before assigning a task, the registered nurse makes sure that the delegation process is appropriate to the situation. To which delegation right does this situation refer? a. Person b. Supervision c. Circumstance d. Communication - A nurse is preparing a client for discharge from the emergency department. Which client statement provides evidence that the client understands the instructions for the prescribed high-dose ampicillin? a. "I should take this medication with meals." b. "I can stop taking this medication when I feel better." c. "I will miss eating my yogurt while taking this medication." d. "I must increase my intake of fluids while taking this medication." b, e - ANS) - Which members of the healthcare team are under dependent status when a task is delegated by the registered nurse (RN)? Select all that apply. a. Unit secretary b. Client attendant c. Registered nurse (RN) d. Primary healthcare provider e. Licensed vocational nurse (LVN) - A healthcare provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? a. Only at bedtime, when famotidine is not taken b. Only if famotidine is ineffective c. At the same time as famotidine, with a full glass of water d. One hour before or 2 hours after famotidine - Which action is appropriate for a nurse who is the triage officer after a high-speed commuter train derailment? a. Evaluating each client to determine priorities for treatment b. Being a liaison between the health care facility and the media c. Deciding the number, acuity, and resource needs for client care d. Assuming leadership for the implementation of the emergency plan - A client with chronic asthma is being cared for in the inpatient care unit. To assess the client on a regular basis would be delegated to which healthcare team member? a. Charge nurse b. Registered nurse c. Patient care associate d. Licensed practical nurse - A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? a. Authority b. Autonomy c. Accountability d. Responsibility - Why does a nurse manager assign a resource person in a healthcare organization? a. To delegate tasks b. To supervise actions c. To serve as a mentor d. To reassign duties to workers a, - What are the overall purposes of delegation? Select all that apply. a. To achieve nursing goals b. To improve client outcomes c. To develop critical judgment skills d. To understand the art of delegation e. To apply delegation decision in clinical nursing practice - What type of relationship between the nurse delegator and delegatee causes the nurse delegator to use the leadership behavior of telling? a. Limited b. Established c. New or developing d. Developing or ongoing - Which behavior of the nurse leader is characterized as delegating according to the Hersey's model? a. Guiding or directing b. Observing or monitoring c. Explaining or persuading d. Encouraging or problem solving - What is the status of the primary healthcare provider as a member of the healthcare team that is in the span of control of a registered nurse (RN)? a. Devoid of legal authority b. Devoid of delegation authority c. Answerable to the nurse manager d. Answerable to the registered nurse - A client is admitted to the emergency department following a motor vehicle accident. The client's wounds are extensive. Which healthcare team member is best suited to care for this client in the emergency ward? a. Charge nurse b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel - What is the purpose of a community emergency response team (CERT)? a. Organizes untrained volunteers to help victims after a disaster b. Assists with staffing hospitals when victims arrive after a disaster c. Trains healthcare professionals in lifesaving skills to help victims of a disaster d. Reduces the need for professional services after a mass casualty incident - The licensed practical nurse (LPN) has been asked to monitor the blood pressure of a client with hypertension. The LPN reports to the registered nurse (RN) that the blood pressure monitor is malfunctioning. Which component of the duty is the LPN practicing? a. Authority b. Supervision c. Responsibility d. Accountability a, b, - Which actions by the nurse help set the stage for a patient-centered interview during the first visit after admission to the healthcare facility? Select all that apply. a. Close the door after entering the room. b. Greet the client using his or her last name. c. Open the curtains to allow plenty of light in the room. d. Introduce oneself with a smile and explain the reason for the visit. e. Obtain an authorization from the client after the interview. a, b, c, - Which groups may be activated by state and federal government authorities to assist during a flooding situation that results from a hurricane? Select all that apply. a. National Guard b. American Red Cross c. Medical Reserve Corps d. Public health departments e. Local emergency departments - An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? a. Confirm the client's relationship first. b. Ask the client's primary healthcare provider. c. Inform the nurse manager and show the records. d. Explain that medical health records are confidential. - A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? a. "Please do not worry, everything will be alright." b. "I am sorry; I do not have any information about the client." c. "You will have to wait for the primary healthcare provider." d. "Please wait; I will update you as soon as I have any information." - Which statement made by the nurse indicates that the client interview is coming to a close? a. "I have just one more question for you." b. "I hope you are comfortable and not in pain." c. "I would like to spend some time to understand your concerns." d. "I assure you that information I gather now will be confidential." - Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles - Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem? a. The nurse takes down notes while the client is talking. b. The nurse leans forward attentively during the discussion. c. The nurse refrains from pausing enough after each question. d. The nurse asks questions that can be answered as "yes" or "no." b, d, e - ANS) - What should the nurse educator instruct a graduate nurse who is seeking employment? Select all that apply. a. Be a role model to the nursing staff b. Attend workshops and conferences c. Motivate other educators on the nursing unit d. Work on developing effective communication e. Approach institutions that provide mentoring - The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview? a. Asking about the client's current concerns b. Ensuring the interview follows a strict agenda c. Asking questions that promote short responses by the client d. Telling the client what he or she should expect from the visit - The nurse manager is designated as a unit Chief during the formulation of a Hospital Incident Command System (HICS) for disaster preparedness. Which responsibility does the nurse manager assume in this role? a. Public information b. Medical command c. Safety and security d. Logistics and operation - The registered nurse (RN) is caring for a client who was admitted to the hospital due to severe diarrhea. The RN assigns the unlicensed assistive personnel (UAP) to check on the client hourly and perform hygiene care as needed. Which concept best explains this situation? a. Leadership b. Delegation c. Supervision d. Assignment - A healthcare team is caring for a client with diabetes insipidus. According to the functional model, which healthcare personnel would the nurse state is qualified to perform all hygienic tasks? a. Registered nurse b. Licensed practical nurse c. Licensed vocational nurse d. Unlicensed assistive personnel b, - The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply. a. Assessing the vital signs b. Performing all hygiene tasks c. Administering oral medications d. Helping the client in changing clothes e. Administering intravenous medications - The nurse is providing postoperative care for a college student who has undergone a knee arthroscopy for a tendon repair. The client is scheduled to be discharged in a few hours and plans to return to the college dormitory and spend the weekend there before returning to class in 2 days. What is most important for the nurse to include in the client's discharge plans? a. Arrange for a taxi to return the client to the dormitory. b. Instruct the client to restrict activities for at least several days. c. Suggest the client spend the weekend in a motel near the hospital. d. Ask the client who is available in the dormitory to provide assistance. - A green-tagged client arrives at the emergency department (ED) after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this client? a. Implementing decontamination measures b. Performing a head to toe physical examination c. Placing a special bracelet with a disaster number d. Taking a digital photo and placing it on the medical record - The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP? a. Client A b. Client B c. Client C d. Client D - A client hospitalized for heart failure is receiving digoxin and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? a. Monitoring vital signs and encouraging a vigorous aerobic exercise program b. Providing written material on the adverse effects of the medication c. Contacting Social Services for a home health nursing consultation d. Teaching the client how to count the pulse - Which intervention does the nurse implement to develop a caring relationship with the client's family? a. Deciding healthcare options for the client b. Identifying the client's family members and their roles c. Declining to inform the client's family after performing a procedure d. Refraining from discussing the client's health with the family - The charge nurse is preparing for the arrival of clients to the emergency department (ED) after a mass casualty incident (MCI). The hospital has an automatic tracking system that is implemented during MCIs. Which decision should the nurse use the system for during this MCI? a. To determine the number of on-call staff needed b. To determine the specific plan to be implemented c. To determine how many casualties of each acuity level can be safety accepted d. To determine how many clients can be safety discharged to allow for new admissions - A client is admitted to the hospital with the diagnosis of acute salmonellosis. Which priority medication will the nurse prepare to administer? a. Opioids b. Antacids c. Electrolytes d. Antidiarrheals - The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking and aspiration after being fed by the UAP. Which right of delegation was violated for this client? a. Task b. Person c. Circumstance d. Communication b, d, e - ANS) - The registered nurse (RN) assigns a task to a licensed practical nurse (LPN) to take care of a client admitted with severe burns. Which tasks are being performed by the LPN in this situation? Select all that apply. a. Performing hygiene tasks b. Monitoring the heart rate c. Evaluating the medical reports d. Monitoring the blood pressure e. Administering the oral medication a, d, e - ANS) - The nurse is trained to work as a member of a disaster preparedness team. Which activities should the nurse be prepared to perform if a disaster were to occur? Select all that apply. a. Triage b. Palliative care c. Home visits to newborns d. Decontamination procedures e. Evaluation of the disaster plan - The nurse is making rounds and stops to check a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel (UAP) ([continuing care assistant (CCA]) will cause the nurse to intervene? a. The client's heels are kept off the bed. b. The UAP (CCA) elevates the client's affected leg on a pillow. c. The UAP (CCA) uses a pillow to keep the client's legs abducted. d. The client uses a walker when ambulating with the UAP (CCA). a, c, e - ANS) - Which care activities would be involved in a correct delegation process? Select all that apply. a. Licensed practical nurse (LPN) cleans the client's body. b. Unlicensed assistive personnel (UAP) provides medication to the client. c. Unlicensed assistive personnel (UAP) assist the client with oral feedings. d. Licensed practical nurse(LPN) evaluates the client's temperature condition. e. Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature. - The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? a. Oxygen therapy b. Cardiac monitoring c. Nutrition supplements d. Venous thromboembolism (VTE) prevention - A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? a. Fruits b. Grains c. Red meat d. Vegetable oils - When evaluating a task performed by a delegatee, the registered nurse finds that the delegatee fails to provide appropriate feedback. Which right of delegation is compromised in this situation? a. Right task b. Right person c. Right supervision d. Right communication - A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? a. Prone with the head turned to one side b. Supine with the knees flexed at 10 degrees c. Lateral with the head slightly elevated and flexed d. Supine with the head in a hyperextended position - The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to? a. Behavioral b. Community c. Physiological d. Health system - Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? a. Avoiding manipulation of the client's limbs b. Asking a family member about any client drug allergies c. Cutting fabric that is stuck to the client's skin with scissors d. Auscultating heart and lung sounds through the client's clothing - The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? a. Red b. Black c. Green d. Yellow - A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide, and long-term steroid therapy has been initiated. What is especially important for the nurse to ensure? a. The client increases sodium intake. b. Protective isolation is established. c. Total daily fluid intake is decreased. d. The client is monitored for an exacerbation of symptoms. - The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document? a. Homans b. Romberg c. Chvostek d. Queckenstedt - Which individual is categorized as one who would be considered as "dependent status"? a. Unit secretary b. Nurse manager c. Registered nurse (RN) d. Licensed practical nurse (LPN) - A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit. When should the nurse take the neonate's mother to visit the infant? a. When the infant's condition has stabilized b. When the infant is out of immediate danger c. When the primary healthcare provider has provided written permission d. When the mother is well enough to be taken to the intensive care unit - Which component of delegation is considered a "two way process"? a. Authority b. Supervision c. Responsibility d. Accountability - Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? a. Treat the victim for shock. b. Start rescue breathing immediately. c. Apply surface pressure to the foot wound. d. Safely remove the victim from the immediate vicinity. - The registered nurse (RN) is the team leader for a group of clients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? a. Taking vital signs b. Providing wound care c. Conducting discharge teaching d. Administering oral medications - A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? a. Monitor the vital signs every 15 minutes b. Maintain the client in the supine position c. Keep the client's lower extremities in extension d. Administer the prescribed oxygen at 4 L/min via nasal cannula - Which client situation may benefit from the nurse issuing a contract regarding the plan of care? a. An infant's parents prior to hospital discharge b. A preschool-age child requiring immunizations c. A school-age child who is active in afterschool sports d. An adolescent who is seeking information regarding birth control - The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? a. "Nice job." b. "Well done." c. "Your performance was good." d. "You performed that procedure safely and professionally." - The registered nurse is delegating tasks for nursing assistants caring for a client who requires more attention. Which element should be considered when selecting the suitable nursing assistant for delegation of a task? a. Time b. Safety c. Stability d. Critical thinking - A nurse is caring for a client 8 hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, how will the nurse create negative pressure in the system? a. Attaching the device to a wall suction unit b. Milking the tubing toward the suction device c. Compressing the device while closing the air plug d. Keeping the device in a position lower than the site of insertion - When tasks are delegated by the registered nurse (RN) to the unlicensed nursing personnel (UNP), who can assume the responsibilities when the RN goes for a break? a. Charge nurse b. Chief nursing officer c. Healthcare provider d. Licensed practical nurse a, - The nurse is assessing the level of readiness before delegating tasks to unlicensed assistive personnel (UAP). According to Hersey's model of situational leadership, what specific factors reflect the level of readiness? Select all that apply. a. Ability b. Honesty c. Reliability d. Willingness e. Conscientiousness b, d, e - ANS) - Which aspects are considered when determining the willingness of a nursing assistant before delegating a task? Select all that apply. a. Ability b. Attitude c. Personality d. Confidence e. Commitment a, b, - The registered nurse (RN) is delegating tasks to licensed practical nurses (LPNs) regarding client care. Which factors should be considered when delegating a task to the LPN? Select all that apply. a. Client's condition b. Complexity of the task c. Number of LPNs available d. Predictability of outcomes e. Relationship status between the delegatee and delegator - The nurse is helping devise a training plan to familiarize health care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? a. Drills b. Tabletop exercises c. Access to the policy d. Computer simulations - What is the nurse's primary outcome goal when managing the care of a client diagnosed with generalized anxiety disorder (GAD)? a. Creating an anxiety-free environment for the client b. Assisting the client with the development of healthy, adaptive coping mechanisms c. Identifying the triggers that produce anxiety in the client d. Providing reinforcement that the client's anxiety issues can be eliminated - A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? a. "I am unable to run a mile (1.6 kilometers) now." b. "I wake up at night short of breath." c. "My wife says I snore very loudly." d. "My shoes seem larger lately." - Hospital administrators for a new facility are formulating a fire evacuation plan as part of the organizational disaster plan. Which is the best resource for the administrators to use during this process? a. The Life Safety Code® b. The Joint Commission c. The Centers for Medicare and Medicaid Services d. The Occupational Safety and Health Administration - Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? a. Anthrax exposure b. Multicasualty incidents c. Mass casualty incidents (MCI) d. Weapons of mass destruction (WMD) a, - The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? Select all that apply. a. "We have to implement annual drills." b. "The plan must include an evacuation plan." c. "Nursing homes are not required to have a plan." d. "Our facility is held to the same standards as hospital facilities." e. "This is an important component to receive insurance payments for care." - Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? A. A motor vehicle accident involving 5 cars. B. A tornado destroying 50 homes and businesses. C. An act of terrorism injuring and killing hundreds of people. D. A hurricane causing flooding and displacing thousands of people. - The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation? a. The situation describes delegation. b. The situation describes assignment. c. The second nurse holds accountability rather than responsibility for the client. d. The second nurse holds responsibility rather than accountability for the client. - What is the priority in preparing health care professionals for any type of disaster? a. Identification of hazards b. Cooperation with state authorities c. Collaboration with local authorities d. Implementation of federal mandates a,b,c, - When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? (Select all that apply). a. "Do you smoke or drink?" b. "When was your last meal?" c. "Do you have any drug allergies?" d. "When was your last tetanus shot?" e. "How would you describe your current pain?" - The healthcare provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? a. "It prevents excessive blood clotting." b. "It suppresses irritability in the ventricles." c. "It improves oxygen supply to heart tissue." d. "The inotropic action increases the force of contraction of the heart." - A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? a. Nursing aide b. Registered nurse (RN) c. Patient care associate (PCA) d. Licensed vocational nurse (LVN) a, - Which nursing actions contribute to a healthcare facility's emergency preparedness and response prior to a natural disaster? (select all that apply) a. Participating in drills b. Evaluating outcomes c. Activating a telephone tree d. Performing a triage assessment e. Discharging clients who no longer require acute care - Which client is most appropriate to be delegated to unlicensed assistive personnel (UAP) based on the given data? a. Client A b. Client B c. Client C d. Client D c,d,e - ANS) - What criteria should a nurse manager use to determine the feasibility of altering an emergency department triage process? (select all that apply) a. Research findings b. Remote capability c. Need for resources d. Readiness of others e. Evaluation of risk factors - A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? a. Monitoring the vital signs b. Evaluating the client response c. Gastric suctioning through vented tube d. Emptying and measuring the gastric drainage - The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? a. Removing the cervical spine collar b. Monitoring for autonomic dysreflexia c. Implementing the logrolling technique d. Administering the prescribed pain medication - The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? a. Nurse aide b. Certified technician c. Cross-trained technician d. Licensed vocational nurse (LVN) - The nurse is assisting a client out of bed. Which is the priority nursing action? a. Monitoring the client's blood pressure b. Assessing the client's level of consciousness c. Ensuring the call bell is within the client's reach d. Assisting the client from a supine to an upright position b, - The nurse manager is delegating tasks to the healthcare team to care for a client who underwent brain surgery. Which individuals on the team share accountability during delegation? Select all that apply. a. Attendant b. Nurse manager c. Certified technician d. Healthcare provider e. Unlicensed nursing personnel (UNP) - A healthcare provider prescribes epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first? a. Demonstrate the injection technique b. Assess the client's readiness to learn c. Explain how to perform sterile technique d. Encourage the client to contact a home healthcare agency a, c, e - ANS) - What must triage nurses employ when prioritizing care with any model? Select all that apply. a. A caring ethic b. Intensive care experience c. A systematic approach to care d. A baccalaureate degree in nursing e. Solid clinical decision-making skills - The primary healthcare provider prescribes a rectal suppository for a client with severe constipation. Which healthcare professional would be delegated the task of administering the suppository? a. Patient care associate b. Licensed practical nurse c. Unlicensed assistive personnel d. Unlicensed nursing personnel - The nurse is providing care to several clients in the emergency department (ED). Which client is the priority when using the three-tiered triage system? a. A client with a simple fracture b. A client experiencing renal colic c. A client with severe abdominal pain d. A client with chest pain and diaphoresis - A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? a. Determine the client's emotional state. b. Give prescribed drugs to promote bronchiolar dilation. c. Provide education about the impact of a family history. d. Encourage the client to use an incentive spirometer routinely. - In which positions should the nurse place a client who has just had a right pneumonectomy? a. Right or left side-lying b. High-Fowler or supine c. Supine or right side-lying d. Left side-lying or low-Fowler - While delegating a specific task, the registered nurse says to the delegatee, "It is important that you measure the client's blood pressure every 15 minutes." What does this situation indicate? a. The delegatee requires little guidance. b. The delegator is providing explanation. c. The delegator is providing more guidance. d. The delegator and delegatee are creating mutual expectations. b, e - ANS) - The registered nurse (RN) is planning to provide feedback to the licensed practical nurse(LPN). Which questions asked by the RN help in eliciting the LPN's work quality? Select all that apply. a. "Are you feeling well today?" b. "How did the patient respond?" c. "Has the task been completed?" d. "Are you willing to perform the task?" e. "What changes were observed in the client?" - As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints, because this may precipitate what? a. Pain b. Swelling c. Nodule formation d. Tophaceous deposits - The registered nurse (RN) delegates a task to a licensed practical nurse (LPN). Which client task can be assigned to the LPN? a. Client A b. Client B c. Client C d. Client D - A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? a. Unstable vital signs b. Decreased urinary output c. High serum potassium levels d. Reduced intravascular fluid volume b, - Which healthcare settings are appropriate for delegating care according to the functional model of nursing? Select all that apply. a. Hospice units b. Emergency units c. Inpatient facilities d. Ambulatory clinics e. Acute care agencies - The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? a. Developing a plan to avoid aspiration b. Assessing the client's condition after tracheostomy c. Providing tracheostomy care using sterile techniques d. Teaching a client and caregiver about home tracheostomy care - The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case? a. Performing hygiene tasks b. Taking and reporting vital signs c. Administering oral pain medications d. Developing a treatment plan for client's pain - Community members have received mailed notices asking them to come to different healthcare agencies within the community at the same time on the upcoming Saturday afternoon. What is the purpose of asking community members to perform this task? a. Test the emergency preparedness plan b. Determine if community members can read c. Measure the effectiveness of mailed communication d. Identify community members who do not work weekends a, b, - What are some challenges faced in the process of delegation? Select all that apply. a. Limited resources b. Large geographic area c. Time-saving considerations d. Vulnerable populations receiving care e. Provision of assistance with activities of daily living - Which is the priority nursing action to decrease the risk for a client developing a hospital-acquired infection? a. Using droplet precautions b. Using contact precautions c. Using airborne precautions d. Using standard precautions - A client who had thoracic surgery is admitted to the postanesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system? a. Ensure the security of the connections from the client to the drainage unit. b. Empty the drainage container and measure and record the amount once a day. c. Verify that there is vigorous bubbling in the wet suction control compartment. d. Check that the fluid level in the water-seal compartment increases with expiration. - A client arrives in the emergency department in cardiac arrest. Which priority action indicates that the nurse is acting as a leader? a. Trying to find the reason for the disease b. Asking for the history of any other diseases c. Waiting for the primary health care provider d. Resuscitating the client using clinical protocols - A nurse delegator assigns work to a delegatee who has the ability and willingness to do the work but the relationship between the delegator and delegatee is relatively new. How is the delegator's behavior described according to Hersey's Model? a. Selling b. Telling c. Delegating d. Participating a, - What are the elements integrated into delegacy? Select all that apply. a. Stability b. Leadership c. Clinical practice d. Critical thinking e. Communication - A client is admitted to the hospital with severe backache and chest discomfort. After reviewing the client's condition, there is a need for 24-hour client care by the registered nurse (RN). Which healthcare professional is responsible for assigning the task to a registered nurse when 24-hour client care is needed? a. Nurse manager b. Nursing supervisor c. Chief nursing officer d. Primary healthcare provider - The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the patient's current condition. Which characteristic of communication has interfered with the delegation process? a. Information decay b. Information salience c. Confidence in abilities d. Synergy between team members - During a nursing team conference, a mental health worker suggests that a client with schizophrenia, paranoid type, be assigned to group therapy. What should the nurse manager explain about this type of therapy for this client? a. Individuals with this disorder respond well to small therapeutic groups. b. Therapeutic group work tends to be threatening to individuals who are suspicious. c. Compliance with unit rules and medication regimens increases as therapeutic group involvement increases. d. Involvement in small therapeutic groups may decrease the regression and dependency associated with institutionalization. - The RN caring for a postoperative hysterectomy client is delegating tasks to the licensed practical nurse (LPN). Which statement made by the RN indicates the principle of right communication of delegation? a. "Does the LPN understand when to report the vital signs?" b. "Can the LPN monitor blood pressure of the client effectively?" c. "Can the LPN provide effective feedback regarding the client's condition?" d. "Does the LPN have enough knowledge regarding administration of intravenous (IV) fluids to the client?" b, - The registered nurse (RN) is caring for a client who underwent ileostomy. Which activity performed by the nurse indicates following the principle of right circumstance of delegation? Select all that apply. a. Assessing the willingness of the delegatee b. Assessing the equipment to determine vital signs c. Providing supervision of the delegatee during the task d. Teaching institutional policies about caring for a client with ileostomy e. Communicating with the delegatee about care management of the client - Which behavior of the delegator with respect to the work delegated to a delegatee is characterized as "selling" according to the Hershey's Model? a. Guiding or directing b. Explaining or persuading c. Observing or monitoring d. Encouraging or problem solving a, b, e - ANS) - Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. a. Treatment b. Stabilization c. Evaluation of interventions d. Formulation of nursing diagnosis e. Decontamination for suspected contamination - What does the decision strategy of "offering" include in delegation? a. Allowing the delegator to examine the situation differently b. Demonstrating the specific task or behavior to improve client care c. Asking questions related to the problem or issue regarding client care d. Making a suggestion to facilitate the achievement of a desirable client care outcome 100 - ANS) - A client has a prescription for an antibiotic in an intravenous piggyback (IVPB) of 50 mL of D5W to run for 30 minutes. The microdrip tubing has a drop factor of 60 gtt/mL. At what rate should the nurse set the IV infusion? Record your answer using a whole number. ______________ gtts/min - Which statement of the nurse is true regarding Hersey's Situational Leadership Model? a. The situational leadership model cannot be applied to real work-related situations. b. The situational leadership model provides a solid foundation for delegation decisions. c. The situational leadership model does not relate to the behavior of the delegatee during delegation. d. The situational leadership model contends that managers should not behave differently on different occasions. a, d, e - ANS) - Which conditions make a delegation more challenging for the registered nurses, delegatees, and clients? Select all that apply. a. Limited resources b. More staff availability c. More client care time d. Greater geographical area e. Vulnerable populations receiving care a, c, e - ANS) - A client is hospitalized with dehydration and dysphagia. Which tasks are appropriate to delegate to a licensed practical nurse? Select all that apply. a. Administer medications b. Perform initial swallow screen c. Assist UAP with ambulating client d. Complete admission skin assessment e. Record vital signs on electronic health record - The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase. The nurse evaluates that teaching is understood when the client identifies which time for medication scheduling? a. At bedtime b. With meals c. One hour before meals d. On arising each morning - The client with methicillin-resistant staphylococcus aureus (MRSA) is admitted to the medical unit. Which of the following tasks should be performed by the registered nurse? a. Feeding b. Administrating oral medication c. Initiating intravenous (IV) antibiotic therapy d. Changing the dressing of a postoperative wound - Which component of delegation is defined as the ability to perform duties in a specific role? a. Authority b. Supervision c. Responsibility d. Accountability - A licensed practical nurse (LPN) was hired recently. Which strategy should be applied by the registered nurse (RN) to open lines of communication between them? a. Telling b. Selling c. Asking d. Offering - A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, what should the nurse ask housekeeping personnel to do? a. Point this out to the client and remove the food. b. Report it to the nursing staff if it happens again. c. Disregard this because it is a common behavior in clients with anorexia. d. Keep a record of when this happens and report it to the nursing staff weekly. a, - A client is hospitalized with a brain injury and a skull fracture. The registered nurse is delegating tasks to the healthcare team. Which member of the healthcare team is suitable to provide client care? Select all that apply. a. Charge nurse b. Chief nursing officer c. Licensed practical nurse d. Newly hired registered nurse e. Unlicensed nursing professional - A registered nurse is teaching a student nurse about the functions and utilization of trauma centers. Which statement of the student nurse indicates effective learning? a. "Clients requiring advanced life support should be sent to a level II trauma center." b. "Most injured clients requiring urgent treatment should be sent to a level I trauma center." c. "Clients requiring stabilization with major injuries should be sent to a level III trauma center." d. "Clients requiring full continuum of trauma services should be sent to a level IV trauma center." - A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? a. "I will change the dressing every day." b. "I will recommend a physical therapy referral." c. "I will provide you with a homecare service referral." d. "I will not allow any family member to be present during dressing change." a, - The registered nurse (RN) has delegated a task to an unlicensed nursing personnel (UNP). After performing the task, the UNP reports to the RN for appraisal. Which statement by the UNP is related to individual accountability? Select all that apply. a. "I take full responsibility for the action performed." b. "I have ensured that the action has achieved the desired outcome." c. "I have ensured that there is a ventilator placed in every intensive care unit." d. "I have established systems for assessing and monitoring the tasks assigned." e. "I have evaluated whether the work environment is conducive to work or not." - Which action, if performed by the nurse, is inappropriate while caring for different clients after a disaster? a. Teaching and supervising volunteers b. Providing on-site first aid and emergency care c. Evacuating injured and uninjured people from a danger area d. Teaching clients about procedures that are needed for safety - A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? a. It is unlikely that the client will regain the ability to walk. b. It prepares them for wearing braces. c. It assists them in overcoming orthostatic hypotension. d. They have the strength in the upper extremities for self-transfer. - Which action by the nurse constitutes constructive feedback for the delegatee? a. Providing verbal attacks on feedback b. Providing feedback to individual delegatee c. Providing nonspecific feedback about the behavior d. Providing open feedback about specific strategies for change - A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? a. Atrial fibrillation b. Forearm laceration c. Migraine headache d. Respiratory infection a, c, - A healthcare team is caring for a postsurgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. a. Changing the dressing b. Ambulating the client c. Administration of oral analgesics d. Reinforcing leg exercise instructions e. Administering intravenous antibiotics - A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? a. "You will receive the anesthesia through a face mask." b. "You will receive medication through an intravenous (IV) catheter." c. "We will give you an oral medication about 1 hour before the procedure." d. "The medicine will be injected into your spine." - The nurse is developing a plan of care for a client who is using ritualistic behavior. Initially the nurse must understand what about the ritual? a. That it is under conscious control b. That it is used primarily for secondary gains c. That it helps the client focus on the inability to cope with reality d. That it helps the client control the level of anxiety the client is experiencing - An administrator for a community hospital notes that actions to help with emergency room visits caused by adverse weather events have not been successful over the last few months. What should the administrator consider implementing to address ongoing issues? a. Interprofessional team b. Monthly data collection processes c. Permanent quality improvement (QI) team d. Evidence-based practice research guidelines - The nurse is assisting a client in labor. Which intervention should the nurse perform as soon as the newborn is delivered? a. Remove nasopharyngeal secretions b. Cover the newborn in a warm blanket c. Determine the newborn's Apgar score d. Place the newborn directly on the mother's abdomen - Which response by the nurse who is earning certification as a member of the Disaster Management Assistance Team (DMAT) indicates accurate understanding regarding the responsibilities of the team? a. "I will be the facility incident commander." b. "I will be a member of an all registered nurse team in the field." c. "I will be covered by the Good Samaritan law as a member of this team" d. "I will be expected to work a three day shift with the supplies we are given." - Which nursing action should be included in the plan of care for a client who has a permanent fixed (asynchronous) pacemaker inserted? a. Instruct the client that it is better to sleep on two pillows b. Encourage the client to reduce activity from former levels c. Teach the client to keep daily accurate records of the pulse d. Inform the client that the pacemaker functions when the heart rate drops below a preset rate - A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client? a. Begin helping the client to write. b. Encourage the client to acknowledge that this disability is permanent. c. Wait for communication to be initiated by the client even if it takes a long time. d. Assist family members to accept the fact that they cannot communicate verbally with the client. b, c, - Which individuals will the emergency department (ED) charge nurse collaborate with during an actual disaster to organize nursing and ancillary services to meet client needs? Select all that apply. a. Paramedics b. Triage officer c. Trauma program manager d. Medical command physician e. Unlicensed assistive personnel - Which of these clients is most appropriate for delegation to a cross-trained technician? a. Client A b. Client B c. Client C d. Client D - Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? a. Face tent b. Venturi mask c. Nasal cannula d. Nonrebreather mask