Leasdership ati questins and Answer
⦁ A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in t
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Leasdership ati questins and Answer
⦁ A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
D. Rescue the clients.
⦁ Pull the fire alarm.
⦁ Confine the fire.
⦁ Extinguish the fire.
⦁ A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?
⦁ Utilitarianism
Rationale: Utilitarianism refers to actions that are right when they contribute to the greatest good.
Nonmaleficence
Rationale: Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.
⦁ Fidelity
Rationale: Fidelity is the duty to keep one's promises or word. It refers to the obligation to be faithful to the agreements, commitments, and responsibilities that one has made to oneself and others.
⦁ Veracity
Rationale: Veracity is the duty to tell the truth. It means that one does not intentionally deceive or mislead clients.
⦁ A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?
"I need to talk to you about unit expectations regarding delegating and completing tasks."
Rationale: This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.
⦁ "Several staff members have commented that you don't do your fair share of the work."
Rationale: This statement is accusatory.
⦁ "If you don't do your share of the work, I will have to inform the nurse manager."
Rationale: This statement is punitive.
⦁ "You have been very inconsiderate of others by not completing your share of the work."
Rationale: This statement is punitive.
⦁ A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon’s medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
⦁ Utility
Rationale: Utility is the ethical principle that the good of many people outweighs the good of one person.
⦁ Paternalism
Rationale: Paternalism is the belief that one individual has the right to make decisions for another. It negates the client’s right to autonomy.
⦁ Justice
Rationale: Justice is the ethical principled based on the belief that everyone should be treated fairly.
Nonmaleficence
Rationale: The nurse is obligated to protect the client’s confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client.
⦁ When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?
⦁ The AP's ability to prioritize
Rationale: Although the nurse could determine the AP’s ability to prioritize, this is not one of the rights of delegation.
The AP has the knowledge and skill to perform the task
Rationale: The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.
⦁ The AP's rapport with clients
Rationale: Although a positive rapport with clients is important, this is not one of the five rights of delegation.
⦁ The AP’s ability to complete the task without assistance
Rationale:
The nurse does not relinquish accountability for supervising the AP; therefore, this is not one of the five rights of delegation.
⦁ While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
⦁ Complete an incident report.
Rationale: The nurse should complete an incident report; however, there is another action the nurse should take first.
⦁ Request the risk manager obtain consent for HIV testing from the client.
Rationale: Although it is important that the client’s HIV status is determined, there is another action the nurse should take first.
Wash the site of injury with soap and water.
Rationale: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.
⦁ Consent to postexposure treatment with antiretroviral medications.
Rationale: Although treatment with antiretroviral medications should be started within 1 to 2 hr after a needle stick injury and be continued for 28 days if the client’s HIV status is positive, there is another action the nurse should take first.
⦁ A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification?
⦁ "I can change who I designate as my health care proxy at any time."
Rationale: This is a correct statement regarding a health care proxy.
⦁ "If I become incapacitated, end-of-life choices will be made by my proxy."
Rationale: This is a correct statement regarding a health care proxy.
"I have to choose a family member as my health proxy."
Rationale: The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.
⦁ "The health care proxy does not go into effect until I am incapable of making decisions."
Rationale: This is a correct statement regarding a health care proxy.
⦁ A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?
⦁ Provide an inservice on medication administration to all the nurses.
Rationale: A recommendation for staff education may be indicated, but this does not assist the committee to identify factors that lead to medication errors.
⦁ Require staff nurses to demonstrate competency by passing a medication administration examination.
Rationale: Ensuring competency in medication administration may be indicated, but this does not assist the committee to identify factors that lead to medication errors.
Review the events leading up to each medication administration error.
Rationale: After a sentinel event, the first step the committee should plan to take is to use root cause analysis to identify the underlying cause or causes that led to the medication errors.
⦁ Develop a quality improvement program for nurses involved in medication administration errors.
Rationale: Although development of a quality improvement program for nurses involved in medication errors may be indicated, this does not assist the committee to identify factors that lead to medication errors.
⦁ A charge nurse has access to the facility’s electronic client records. It is appropriate for the charge nurse to share her personal password with whom?
⦁ The nurse manager
Rationale: A nurse manager authorized to have access to a computer will have a personal password.
No one
Rationale: Computer passwords cannot be shared with others for any reason. Any facility employee authorized to have access to the database on a computer will have a personal password.
⦁ A nursing student who is completing a preceptorship on the unit
Rationale: A nursing student who is authorized to have access to the database on a computer will have a personal password.
⦁ The unit clerk
Rationale: A unit clerk authorized to have access to a computer will have a personal password.
⦁ A nurse on a medical-surgical unit is reconciling a newly admitted client’s medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information?
⦁ The American Hospital Association requires accredited facilities to have protocols in place requiring
medication reconciliation.
Rationale: The Joint Commission requires accredited facilities to have protocols in place requiring medication reconciliation.
B. The purpose of medication reconciliation is to prevent adverse medication reactions.
Rationale: Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes.
C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity.
Rationale: This action by the nurse does not demonstrate the ethical principal veracity, which means telling the truth. The nurse who performs medication reconciliation is demonstrating the ethical principle beneficence, which means the nurse takes action to promote good, and nonmaleficence, which means the nurse takes action to prevent harm.
D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.
Rationale: The International Council of Nurses Code of Ethics stipulates that nurses have a responsibility to promote health and prevent illness, but it does not mandate medication reconciliation. The Institute for Healthcare Improvement recommends the nurse perform medication reconciliation when a client is transferred and The Joint Commission requires medication reconciliation when a client is admitted and when a client is discharged.
⦁ A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
⦁ Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
Rationale: The nurse should attempt to get the client to sign the AMA form because this measure can help to defend the facility if a lawsuit ensues; however, the nurse should not tell the client she will not be permitted to leave the facility because this action could lead to charges of false imprisonment.
⦁ Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
Rationale: This action by the nurse is uncaring and the client could perceive it as a threat.
C. Explain the risk the client faces if she leaves the facility.
Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3.The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.
D. Ask the security department to guard the room to the client’s door.
Rationale: This action could lead to charges of false imprisonment.
⦁ A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?
⦁ Delivering meal trays to clients in their rooms
Rationale: Delivering meal trays is an appropriate task to delegate to a volunteer.
⦁ Assisting a client who has difficulty seeing the foods on the tray while eating
Rationale: Assisting a client who has a vision deficiency to eat is an appropriate task to delegate to a volunteer.
⦁ Delivering a routine urine specimen to the laboratory
Rationale: Delivering a routine urine specimen is an appropriate task for a volunteer.
D. Observing a postoperative client who is confused
Rationale: A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.
13. An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first?
A. Gather data about the nurse’s work performance and attendance history.
Rationale: The first action the nurse should take is to conduct an investigation and determine if the allegations are true.
⦁ Approach the involved nurse to discuss the behavior.
Rationale: The nurse should approach the involved nurse to discuss the behavior; however, there is another action the nurse should take first.
⦁ Notify the risk manager.
Rationale: The nurse should notify the risk manager; however, there is another action the nurse should take first.
⦁ Refer the nurse to the board of nursing diversion program.
Rationale: The nurse should report the incident to the board of nursing if the suspicion of drug diversion is founded; however, there is another action the nurse should take first.
⦁ A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client’s family about organ donation. The client’s spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?
A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse’s organs."
Rationale: The nurse should avoid giving her personal opinion.
B. "What do you think your spouse would have wanted?"
Rationale: Federal law requires facilities to have policies and procedures in place about making a request for organ and tissue donation at the time of death. The request is made by an employee, often a social worker, who has advanced training and can request the donations in a caring, sensitive manner. The role of the nurse is to provide emotional support to the family. Family members should consider the deceased person’s wishes when making their decision.
C. "Most religions support organ donation, so don’t let that stand in the way."
Rationale: While it is true that most religions support organ donation, there is no indication that this is a concern felt by the client’s spouse.
D. "Don’t you think you will feel a little better about the situation if you donate your spouse’s organs?"
Rationale: The nurse should not provide the client’s spouse with false reassurance.
15. A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate?
A. "If you render aid in an accident, do not leave the scene until another competent person can take over."
Rationale: Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives.
⦁ "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse."
Rationale: Good Samaritan laws require the nurse to render the level of care expected by a competent, prudent nurse in a similar situation. To win a malpractice suit against the nurse, the victim must prove the nurse was grossly negligent or careless.
⦁ "Federal laws require a licensed nurse to render aid in an emergency."
Rationale: Good Samaritan laws are state laws. Only a few states have duty to rescue laws, for example: Vermont, Minnesota, and Wisconsin. The nurse should know the laws of the state.
⦁ "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws."
Rationale: Good Samaritan laws protect the nurse in an emergency. Even in volunteer situations, Good Samaritan laws do not provide protection because in most cases an emergency does not exist.
⦁ A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
⦁ The nurse identifies a broken piece of equipment.
Rationale:
This issue should be resolved by removing the equipment from the client care area and placing a work order for its repair.
⦁ A staff member does not show up to work her assigned shift.
Rationale: This is a staff problem that should be resolved between the staff member and the nurse manager.
C. A client discovers that his dentures are missing.
Rationale: This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.
D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.
Rationale: An incident report is not necessary for this situation.
17. A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first?
A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately.
Rationale: Sexual harassment is unwanted sexual advances made in the context of a relationship of unequal power or authority. It is experienced as offensive in nature. The nurse should first start by taking the most direct measure: confronting the hiring manager and insisting the harassment stop.
⦁ Report the behavior to the nurse manager.
Rationale: The nurse should report the behavior to the nurse manager; however, there is another action the nurse should take first.
⦁ Create a written document of the incident and store the document in a safe place.
Rationale: The nurse should create a written document of the incident and store the document in a safe place; however, there is another action the nurse should take first.
⦁ Seek help from a trustworthy friend.
Rationale: The nurse should seek help from a trustworthy friend; however, there is another action the nurse should take first.
⦁ A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?
⦁ "I feel you are being inconsiderate of the other team members."
Rationale: This statement is accusatory and can create barriers to communication.
⦁ "I have to let the director of nursing know about this situation."
Rationale: Delaying conflict resolution or involving superiors without first attempting to resolve the situation can create adversarial feelings.
C. "I need to talk to you about the unit policies regarding client assignments."
Rationale: This statement opens the conversation in a nonthreatening way and places the focus on the issue of policies rather than on any personal desire or characteristic of the individual.
D. "You always get your choice of assignment and don't work your fair share."
Rationale: This is an inflammatory statement that will only cause more barriers to the resolution of the conflict.
⦁ A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
⦁ Veracity
Rationale: Veracity is truthfulness. It requires the nurse to tell the truth to every client and to make sure the client fully understands the message.
⦁ Autonomy
Rationale: Autonomy is the right to independence and personal freedom, which leads to the primacy of self-determination.
⦁ Fidelity
Rationale: Fidelity is the duty to keep promises. It refers to the obligation to be faithful to agreements, commitments, and responsibilities that are made.
D. Nonmaleficence
Rationale: Nonmaleficence, as a principle in research, is the obligation to do no harm to the client.
Intentionally exposing clients to serious or permanent harm is unacceptable. Should such a situation emerge during the conduct of a study, the study should be terminated immediately.
20. A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?
A. Quietly tell the APs that this is not appropriate.
Rationale: The nurse has a professional duty to protect the client’s confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.
⦁ Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit.
Rationale:
Although it might be appropriate to ask the manager to review the importance of maintaining confidentiality with the staff on the unit, there is another action that is the priority.
⦁ Complete an incident report.
Rationale: Although the nurse has a responsibility to complete an incident report when there is an accident or unusual occurrence, there is another action that is the priority.
⦁ Document the occurrence in a personal log.
Rationale: Although the nurse should keep notes about the occurrence for legal protection, there is another action that is the priority.
21. A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?
A. Take an arterial blood gas (ABG) specimen to the laboratory.
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.
⦁ Transport a client to the radiology department for an x-ray.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the priority.
⦁ Pass fresh water to clients on the unit.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the priority.
⦁ Obtain a routine urine sample from a newly-admitted client.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the priority.
⦁ A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?
A. Veracity
Rationale: The ethical principle of veracity requires the nurse to tell the truth and not to intentionally deceive or mislead clients.
B. Autonomy
Rationale: The issue here is the client's right to choose. The ethical principle of autonomy applies to an individual's right to choose and control what happens to him. Respecting autonomy requires the nurse to recognize the client's choice is based on personal values and those values do not have to be shared by the nurse.
C. Fidelity
Rationale: The ethical principle of fidelity requires the nurse to keep promises by being faithful to agreements, commitments, and responsibilities.
D. Justice
Rationale: The ethical principle of justice requires the nurse to treat everyone fairly.
⦁ A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.)
A. Provide discharge instructions to a confused client's spouse.
B. Obtain vital signs from a client who is 6 hr postoperative.
C. Administer a tap-water enema to a client who is preoperative.
D. Initiate a plan of care for a client who is postoperative from an appendectomy.
E. Catheterize a client who has not voided in 8 hr.
Rationale: Providing discharge instructions to a confused client's spouse is incorrect. The nurse is responsible for delegating a task to the person who has proper training and skill. Client education is the responsibility of the registered nurse.
Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN.
Administering a tap-water enema to a client who is preoperative is correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN.
Initiating a plan of care for a client who is postoperative from an appendectomy is incorrect. Planning care is the responsibility of the registered nurse.
Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.
⦁ A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following?
⦁ Ensuring the charge nurse is available to witness the client’s signature on the consent form
Rationale: The nurse caring for the client can witness the client’s signature on the consent form. It is not necessary to ask the charge nurse to serve as the witness.
⦁ Explaining the risks involved with the procedure
Rationale: The surgeon must explain the risks involved with the procedure. A nurse who attempts to explain the risks involved with the procedure faces the possibility of legal action if the information is incomplete or incorrect. Additionally, the nurse is interfering with the
client-provider relationship.
⦁ Discussing alternate treatment options
Rationale: Discussing alternate treatment options is the responsibility of the surgeon. A nurse who
attempts to discuss alternate treatment options faces the possibility of legal action if the information is incomplete or incorrect. Additionally, the nurse is interfering with the client-provider relationship.
D. Determining the client’s level of understanding about the procedure
Rationale: In the role of client advocate, the nurse is responsible for ensuring the client understands the information provided by the surgeon and must notify the surgeon if the client has questions.
⦁ A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?
A. An expert nurse provides testimony that the nurse should have handled the situation differently.
Rationale: Although expert nurses can be called to testify by attorneys for both the plaintiff and the defendant, this is not the standard used to determine the nurse's liability.
B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation.
Rationale: The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.
C. The client's attorney states that injury to the client could have been prevented.
Rationale: Although the client's attorney can offer an opinion regarding how injury to the client occurred and could have been prevented, this is not the standard used to determine the nurse's liability.
D. The client's provider testifies the nurse was at fault for the injury.
Rationale: Although the client's provider can be called to testify about the injury, this is not the standard used to determine if the nurse was negligent.
⦁ A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?
⦁ Availability of resources, such as fire extinguishers
Rationale: Structure audits evaluate the availability of resources.
⦁ Nursing staff ratios
Rationale: Structure audits measure staffing ratios.
C. Quality of nursing care provided
Rationale: Process audits evaluate the quality of care nurses provide. They also determine if the care provided by nurses is consistent with established facility policy.
D. Length of facility stay for a cohort of clients
Rationale: Outcome audits measure the outcome of the care provided and include elements such as morbidity, mortality, and length of facility stay.
27. Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?
A. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy
Rationale: A client who is scheduled for an elective surgery is medically stable and is not bedridden; therefore, the nurse should recommend this client for discharge.
⦁ An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax
Rationale: A client who has a pneumothorax is unstable and needs rest, oxygen, and observation. If the client’s condition becomes worse, a chest tube may be required. Therefore, the nurse should not recommend this client for discharge.
⦁ A middle adult who is 36 hr postoperative from an open laminectomy
Rationale: A client who is postoperative from an open laminectomy is at risk for complications, especially 24 to 48 hr after surgery. Therefore, this client is not stable and the nurse should not recommend this client for discharge.
⦁ An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32
Rationale: Diabetic ketoacidosis is a serious complication of diabetes mellitus. It usually develops in conjunction with an infection, but it can also develop due to poor nonadherence to prescribed care. This client’s pH is below the expected reference range; therefore, this client is not stable and the nurse should not recommend this client for discharge.
⦁ A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse’s signature on the consent form indicates which of the following?
A. Determines the client does not have a mental illness
Rationale: Clients who have a mental illness have the right to make decisions about their health care unless they have been found to be incompetent by a court of law.
B. Confirms the client appears competent to provide consent
Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the client was the one who signed the consent form and that he seems to be competent to give consent.
C. Asserts the nurse has explained the risks and benefits of the procedure
Rationale: It is the responsibility of the provider to explain the risks and benefits of the procedure to the client.
D. Records that the client’s spouse agrees the procedure is necessary
Rationale: Although support from the client’s spouse can be a factor when the client considers surgery, the ethical principle autonomy is a fundamental principle and it supports the client’s right to self-determination.
29. A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?
A. Ask what she will be assigned to do.
Rationale: Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available to her.
⦁ Determine if she has the skills to complete the assignment.
Rationale: The nurse should perform a self-evaluation to determine if there are discrepancies between expectations and skills. Discrepancies can lead to unsafe client care.
⦁ Identify her options.
Rationale: After the nurse gains knowledge about the assignment and completes a self-evaluation, the nurse can either accept or refuse the assignment.
⦁ Notify the nurse manager about her concerns for client safety.
Rationale: The nurse should not notify the nurse manager about her concerns for client safety until she has determined she has the skills to safely provide client care.
30. A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate?
A. “Let’s talk about your concerns about the new policy.”
Rationale: The nurse manager should meet with the nurse to allow an open forum for the nurse to verbalize the reasons for her reluctance to adopt the new policy.
⦁ “Why didn’t you voice your concerns before the new policy was implemented?”
Rationale: This statement is accusatory and will likely make the nurse defensive.
⦁ “Being open to change is an expectation of the nurses who work on this unit.”
Rationale: While being open to change is an expectation of a professional nurse, this statement does not address the issue. It avoids the issue at hand.
⦁ “You should support this policy change because it was based on evidence-based practice.”
Rationale: Evidence-based practice is the use of knowledge from research to support delivery of nursing
care. Its use is important when nurses consider a policy change related to client care; however, this statement does not address the issue. It avoids the issue at hand.
⦁ A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client’s provider, and completes an incident report, which of the following actions should the nurse take?
A. Make a copy of the incident report for the provider.
Rationale: Incidence reports are confidential tools used by the facility to improve client care. They are never copied.
B. Submit the incident report to the risk manager.
Rationale: The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.
C. Place the incident report in the client's chart.
Rationale: Incident reports are confidential tools used by the facility to improve client care. They are never placed in the client's chart. If there is a lawsuit and the incident report is in the client’s chart, the attorney can subpoena the document and use its contents as evidence.
D. Document in the chart that an incidence report has been filed.
Rationale: Incident reports are confidential tools used by the facility to improve client care. They are never referred to in a client's chart. If there is a lawsuit and the incident report is referenced in the client’s chart, the attorney can subpoena the document and use its contents as evidence.
32. A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
A. Transporting a school-age client who is in traction to another department
Rationale: To ensure client safety, the nurse is responsible for delegating tasks to the right people. The nurse should avoid assigning this task to the volunteer because the individual who performs this task must understand the principles of traction. A volunteer does not have the requisite skill to perform this task.
⦁ Playing a computer video game with an adolescent who has sickle cell disease
Rationale: This is an appropriate and safe assignment for the volunteer. It provides both socialization and diversional activity to the client in traction.
⦁ Reading a book to a preschool client who has AIDS
Rationale: This is an appropriate and safe assignment for the volunteer. It provides a diversional activity for the client.
⦁ Rocking an infant who was admitted for croup
Rationale:
This is an appropriate and safe assignment for the volunteer. It provides comfort for the client.
⦁ A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?
⦁ "Let's talk about something else."
Rationale: While this appears to be a response meant to change the subject, this response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.
⦁ "Whether or not I am a good lover is irrelevant."
Rationale: While this appears to be a response meant to change the subject, this response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.
C. "Speaking to me like that makes me uncomfortable."
Rationale: This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.
D. "You need to lower your voice. Others can hear you."
Rationale: This response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse. In fact, it could be considered by the harasser as encouragement.
⦁ A nurse in a provider’s office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
A. BUN 15 mg/dL
Rationale: This BUN level is within the expected reference range. It does not require follow up by the nurse.
B. Platelet count 60,000/mm3
Rationale: This platelet count is below the expected reference range. A low platelet count places the client at risk for bleeding; therefore, the nurse should follow up on this finding.
C. WBC 6,000/mm3
Rationale: This WBC is within the expected reference range and does not require follow up by the nurse.
D. Hemoglobin 14 g/dL
Rationale: This hemoglobin level is within the expected reference range and does not require follow up by the nurse.
⦁ A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
⦁ Collect a stool sample for ova and parasites from a school-age child
Rationale: Although the AP should collect a stool sample for ova and parasites, there is another task the AP should perform first.
⦁ Engage a toddler in play.
Rationale: Engaging a toddler in play is important because it provides diversion and promotes the toddler’s sense of security, but there is another task that the AP should perform first.
⦁ Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
Rationale: Although the AP should provide personal hygiene measures for the adolescent, including washing the client’s hair, there is another task the AP should perform first.
D. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
Rationale: The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first.
36. A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
A. Keeping an appointment with a client
Rationale: Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity.
⦁ Allowing a new mother to hold her stillborn infant
Rationale: Beneficence is the duty to do good for others. Allowing a grieving mother an opportunity to spend time with her infant helps her to process her loss and is an example of beneficence.
⦁ Confirming that a client going for surgery has signed a consent form
Rationale: The ethical principle of autonomy describes an individual's right to choose. In health care, autonomy is the principle underlying informed consent, the right to refuse treatment, and the right to appoint a surrogate decision maker.
⦁ Refusing to disclose information about a client to the media
Rationale: Confidentiality is not disclosing a client's personal health care information to unauthorized individuals or other entities.
⦁ A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?
⦁ Preventing cross-contamination of clients
Rationale: In a disaster, the nurse must be able to segregate clients to prevent contamination of a nonexposed client with an exposed client, and thereby limiting the spread of the unknown toxin.
⦁ Performing concise client assessment
Rationale: In the triage setting, the nurse provides essential care; therefore, the nurse must conduct concise client assessments for triage purposes.
C. Transferring a client to the discharge location
Rationale: Nursing care in a disaster setting focuses on essential care. The nurse should recognize nonskilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel.
D. Maintaining a client tracking system
Rationale: It is imperative for the nurse to maintain a client tracking system in a disaster situation. Disaster tags are numbered and include information such as triage priority, name, address, medications given, and treatments provided. These tags should remain with the client throughout his movement within the facility.
⦁ A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
⦁ Wound drainage for culture
Rationale: Collecting drainage from a wound for culture requires the use of sterile technique; therefore, the nurse should not delegate this task to the AP.
⦁ Urine from an indwelling catheter
Rationale: Urine from an indwelling catheter requires the use of sterile technique; therefore, the nurse should not delegate this task to the AP.
⦁ Blood for PaCO2
Rationale: PaCO2 is one component of arterial blood gases (ABGs). Only individuals who are specially trained to draw blood from a radial, brachial, or femoral artery, such as nurses, medical technicians, and respiratory therapists, should perform this task; therefore, the nurse should not delegate this task to the AP.
D. Random stool specimen
Rationale: The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required.
⦁ A nurse on a medical-surgical unit is preparing to contact a provider about a client’s condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client’s postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client’s oxygen saturation level and heart rate in which component of the SBAR report?
⦁ Situation
Rationale: The nurse should state his name, the client’s name, the name of the facility, the client’s medical diagnosis, and a general description of what is going on in this section of the report.
⦁ Background
Rationale: The nurse should provide information about the client’s postoperative status in this section of the report.
C. Assessment
Rationale: The nurse should include his assessments in this level of the report. For example, the client’s oxygen saturation level and the client’s apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing.
D. Recommendation
Rationale: The nurse makes a recommendation on how to resolve the problem in this section of the report.
40. A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
A. A dependent adult admitted for the treatment of a spiral fracture
Rationale: Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult.
⦁ A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
Rationale: Although the use of street drugs is illegal, the track marks may be present from scarring due to prior use. The nurse would not be required to report this finding to law enforcement.
⦁ A young adult client admitted for acute glomerulonephritis following a viral infection
Rationale: The nurse is responsible for reporting a number of infections as identified by the Centers for Disease Control as reportable to health authorities; however, acute glomerulonephritis following a viral infection is not a reportable infection.
⦁ An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Rationale:
An emancipated minor has the legal authority to make decisions about his health care. Although the client’s decision to leave the facility without treatment can place him at risk for a poor outcome, the nurse should not report this situation to an outside agency.
41. A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
A. Check the client's medical record for the provider's prescription.
Rationale: The nurse should use the client’s medical record to verify the provider prescribed an enema for the client.
⦁ Explain to the client that the provider prescribed the procedure.
Rationale: This option ignores the client's concern about whether or not an enema is prescribed.
⦁ Assure the client that enemas are commonly prescribed for constipation.
Rationale: This option ignores the client's concern about whether or not an enema is prescribed.
⦁ Inform the charge nurse that the client refused the enema.
Rationale: The client did not refuse the enema; therefore, this action is not appropriate.
42. A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
A. Euphoria
Rationale: Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors.
⦁ Rhinorrhea
Rationale: Rhinorrhea can occur with opiate withdrawal, but it is not an effect from the medication.
⦁ Hallucinations
Rationale: Hallucinations are an adverse effect of cannabis.
⦁ Dilated pupils
Rationale: Constricted pupils are an adverse effect of opioid analgesics.
⦁ A nurse is caring for a client who has advanced lung cancer. The client’s provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?
A. "I will have to be admitted to a long-term care facility in order to receive hospice care."
Rationale: Hospice care is provided in a long-term care facility; however, hospice care is also provided in a number of other settings, including the client’s home and in an assisted living facility.
B. "I should expect the hospice team to help me manage my dyspnea."
Rationale: Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.
C. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy."
Rationale: Hospice care is available to clients who have a prognosis of 6 months or fewer to live.
D. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
Rationale: Hospice care provides comfort care for the client, but does not include curative treatment.
⦁ A nurse manager has received information from the facility’s risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?
A. Complaint phase
Rationale: During the complaint phase, the plaintiff files a document alleging the defendant failed to provide the expected level of safe care.
B. Discovery phase
Rationale: During the discovery phase, both attorneys for the plaintiff and the defendant obtain relevant information about the case. This includes witnesses’ depositions.
C. Decision phase
Rationale: During the decision phase, the judge or jury issues a verdict.
D. Trial phase
Rationale: During the trial phase, the facts are presented to the judge or jury.
⦁ A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
A. Assessing the current health status of the client
Rationale: This action is a nursing responsibility. The nurse should collect baseline data from the client and participate as a member of the interdisciplinary team.
B. Explaining the operative procedure, risks, and benefits
Rationale: Explaining the procedure and any risks that may be associated with it is the responsibility of the
person performing the procedure. This is not a nursing responsibility.
C. Reviewing preoperative laboratory test results
Rationale: This action is a nursing responsibility. Reviewing preoperative laboratory test results determines if any values outside the expected reference range could cause surgical complications.
D. Ensuring that a signed surgical consent form was completed
Rationale: This action is a nursing responsibility. A signed surgical consent form ensures proper surgical protocol is carried out.
46. An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
A. "There is a higher risk of infection for our clients associated with artificial nails."
Rationale: Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.
⦁ "You should know that artificial nails have a very unprofessional appearance."
Rationale: This is not the reason that artificial nails are prohibited in the health care setting. Additionally, this statement is aggressive and condescending.
⦁ "I want you to review the facility’s policy on personal attire before you begin the shift."
Rationale: This statement is passive and does not directly address the issue.
⦁ "Why would you wear artificial nails to work when you know it’s against the rules?"
Rationale: This statement is aggressive and condescending.
47. A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client’s family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
A. Invoking implied consent
Rationale: The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client’s best interest. The neurosurgeon should document the specifics of the situation in the client’s medical record.
⦁ Delaying the surgery until a member of the client’s family is reached
Rationale: This action places the client at risk for a poor outcome; therefore, this is not the action the
nurse should anticipate.
⦁ Asking the client to sign the surgical consent form
Rationale: The neurosurgeon should not ask the client to sign the consent form because he is sedated from the morphine. A client who is disoriented or unable to function because of the administration of a medication, such as morphine, is not competent to sign the surgical consent form.
⦁ Prescribing naloxone to reverse the effects of the morphine
Rationale: The purpose of naloxone is to reverse the effects of opioid toxicity. The neurosurgeon should not prescribe naloxone for the client because it can reverse the analgesic effects of morphine.
⦁ A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
⦁ An adolescent female client who is belligerent and has slurred speech
Rationale: This client is displaying the effects of excessive alcohol intake and needs care. However, there is another client who has a higher priority need and should be cared for by the provider first.
⦁ A toddler who has a laceration on his forehead and is screaming
Rationale: The nurse should apply pressure to the site of laceration and work with the parent to decrease the toddler’s anxiety. However, there is another client who has a higher priority need and should be cared for by the provider first.
C. A middle adult male who is diaphoretic and reports epigastric pain
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction.
D. A young adult with a painful sunburn of his face and arms
Rationale: A sunburn is a superficial burn and the client needs to be cared for by the provider. However, there is another client who has a higher priority need and should be cared for by the provider first.
49. A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
A. Pull the curtain around the client's bed.
Rationale: The nurse should close the door to the client’s room and pull the curtain around the client’s bed to ensure the client’s right to privacy.
⦁ Wash the client’s arms and hands first.
Rationale: The nurse should wash the cleanest area of the body, the client’s face, first.
⦁ Use a washcloth to wipe the client’s eyes from the outer canthus to the inner canthus.
Rationale: The nurse should use a clean washcloth to wipe the client’s eyes from the inner canthus to the outer canthus.
⦁ Fill the bath basin with tap water that is 39° C (102.2° F).
Rationale: The nurse should maintain warmth for the client by filling the bath basin with water that is between 43° C and 46° C (110° F and 115° F).
⦁ A nurse on a medical-surgical unit has accepted a transfer to the intensive care unit (ICU). Prior to transfer to the ICU, the nurse completes an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles?
⦁ Veracity
Rationale: Veracity is the duty to tell the truth. A nurse who tells her client the truth is demonstrating the principle veracity.
⦁ Autonomy
Rationale: Autonomy is the client’s right to make his own decisions about health care. When the nurse supports the client’s right to make decisions about health care, the nurse is demonstrating the ethical principle autonomy.
⦁ Fidelity
Rationale: Fidelity is the duty to keep one's promises or word. When the nurse keeps her promise to the client, she is demonstrating the ethical principle fidelity.
D. Nonmaleficence
Rationale: Nonmaleficence consists of actions taken to prevent client harm. When the nurse completes an advanced education program that will prepare her to provide safer care in the ICU, the nurse is demonstrating the ethical principle nonmaleficence.
51. A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?
A. Give positive feedback directly to the AP.
Rationale: Positive reinforcement is one of the most effective ways to recognize an employee’s ability and to motivate the employee.
⦁ Tell other nurses what an effective team member the AP is.
Rationale: Although it is important to share information about the excellent care the AP provides, there is another action the charge nurse should take first.
⦁ Nominate the AP for the Employee of the Month award.
Rationale:
Although offering rewards is an effective way to recognize an employee’s ability, there is another action the charge nurse should take first.
⦁ Detail the AP's contributions to the nurse manager.
Rationale: Although it is important to share information about the excellent care the AP provides, there is another action the charge nurse should take first.
⦁ A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?
⦁ Discussing advance directives with the client and the client's family
Rationale: Discussing advance directives with the client and the client's family is an example of promoting client autonomy by respecting the client's right to self-determination.
⦁ Providing comfort care measures to the client
Rationale: Providing comfort care measures to a client who is dying is an example of the principle of beneficence, which is a moral obligation to act to benefit others.
C. Withholding a dose of narcotic pain medication when the client has respiratory depression
Rationale: The principle of nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence.
D. Allowing the client's family unlimited visitation at the time of death
Rationale: Allowing the client's family unlimited visitation at the time of death is an example of the principle of beneficence, which is the moral obligation to act in the interest of others.
⦁ A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
Rationale: Having a chronic disease does not make a client eligible for hospice services. The nurse should recommend home health services for this client.
B. A client who has terminal cancer and needs assistance with pain management
Rationale: A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.
C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
Rationale: Having a stroke with no one to care for him during the day does not make a client eligible for hospice services. The nurse should recommend adult day care services for this client.
D. A client who has dementia and needs help with activities of daily living
Rationale: Having dementia and needing help with ADLs does not make a client eligible for hospice services. The nurse should recommend assisted living for this client.
⦁ A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client’s rights and is an example of which of the following?
⦁ Slander
Rationale: Making false statements that damage a client’s reputation is slander.
⦁ Invasion of privacy
Rationale: Violating a client’s confidentiality is an invasion of privacy.
⦁ Defamation of character
Rationale: Writing derogatory statements about a client’s refusal of treatment is defamation of character.
D. False imprisonment
Rationale: Unlawfully restraining a client is false imprisonment. Clients have the right to refuse treatment.
⦁ A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?
⦁ Complete an admission assessment for a client who has COPD.
Rationale: It is not within the scope of practice for an LPN to complete an admission assessment. The LPN can contribute data, but the RN must complete the plan of care.
⦁ Measure I&O for a client who has an indwelling urinary catheter.
Rationale: Even though measuring I&O is within the scope of practice of an LPN, this task does not require a licensed personnel to perform it; therefore, the RN should delegate this task to the AP.
C. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.
Rationale: Reinforcing teaching with a client is within the scope of practice of a LPN; therefore, the RN should delegate this task to the LPN.
D. Develop a plan of care for a client who has cholecystitis.
Rationale: It is not within the scope of practice for an LPN to develop a plan of care. The LPN can contribute to the plan of care, but the RN is responsible for the development of the plan.
⦁ A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
A. Demonstrate the technique to instill eye drops.
B. Ambulate a client who has a cane.
C. Irrigate a wound.
D. Transfer a client to a stretcher.
E. Record urinary output.
Rationale: Demonstrate the technique to instill eye drops is incorrect. It is not within the scope of practice for an AP to demonstrate medication administration. An RN should perform a task that requires client teaching.Ambulate a client who has a cane is correct. Ambulating a client who has a cane is within the scope of practice for an AP.Irrigate a wound is incorrect. It is not within the scope of practice for an AP to irrigate a wound. An RN should perform this task.Transfer a client to a stretcher is correct. Transferring a client to a stretcher is within the scope of practice for an AP.Record urinary output is correct. Recording urinary output is within the scope of practice for an AP.
⦁ A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
⦁ A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
Rationale: A client who has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min is stable; therefore, there is another client the nurse should have the provider care for first.
⦁ A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge
Rationale: A client who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge is stable; therefore, there is another client the nurse should have the provider care for first.
C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Rationale: A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.
D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
Rationale: A client who has sickle cell disease and reports pain is stable; therefore, there is another client the nurse should have the provider care for first.
⦁ A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
A. A client who has diarrhea and requests clear liquids for breakfast
Rationale:
Although this client is at risk for fluid volume deficit and needs fluid replacement, there is another client who has a higher priority need.
B. A client who has a cast on the left leg and reports numbness and paresthesia
Rationale: The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.
C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Rationale: Although this client’s blood glucose is not within the expected reference range and the nurse might need to administer hypoglycemic medication, there is another client who has a higher priority need.
D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
Rationale: Although this client’s temperature is above the expected reference range and the nurse might need to administer an antipyretic, there is another client who has a higher priority need.
⦁ A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
A. "The client should be seen by a neurologist."
Rationale: This statement is the recommendation for action, which is the R step in the SBAR tool.
B. "The client was found unconscious on the floor in her home."
Rationale: This statement is the background or context of the situation, which is the B step in the SBAR tool. The background portion should provide information that is pertinent to the current situation.
C. "There are no provider’s prescriptions available."
Rationale: This statement is the situation as it relates to the client, which is the S step in the SBAR tool.
D. "The client is disoriented. Pupils are slow to respond to light."
Rationale: This statement is the assessment as it relates to the identified problem, which is the A step in the SBAR tool.
⦁ A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?
⦁ The most experienced nurse receives the more complex clients
Rationale: The charge nurse does not need to assign all the complex clients to the most experienced nurse. If there is an increase in supervision, a complex client can be assigned to a less experienced nurse to increase the nurse's confidence and skill level.
⦁ Personal comfort level in making the assignments
Rationale: The charge nurse's role requires her to be adequately prepared and make appropriate assignments.
⦁ Social relationships between nurses working the oncoming shift
Rationale: The charge nurse should be aware of the right person doing the right task on the right person. Social relationships between the nurses should not be considered when making assignments.
D. The physiologic status of the clients on the unit
Rationale: Making assignments requires knowing the physiologic status of the clients on the unit, such as the stability of the clients' vital signs, the amount of health education they need, and the complexity of care involved. Clients who have an unstable physiologic status may require a higher level of skilled care.
⦁ A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
⦁ Assigning two assistive personnel (AP) to ambulate all clients
Rationale: Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of the APs. It is not an example of overdelegation.
⦁ Assigning a new graduate nurse to perform a wet-to-dry dressing change
Rationale: Assigning a new graduate nurse to perform a wet-to-dry dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
C. Assigning the most efficient AP to perform glucometer monitoring for each client
Rationale: Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.
D. Assigning the most competent RN to perform a central line dressing change
Rationale: Assigning the most competent RN to perform a central line dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
⦁ A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)?
⦁ Developing the plan of care for a client who has an amputation
Rationale: Developing a plan of care is not within the LPN's scope of practice.
⦁ Evaluating the outcomes of a new postoperative client
Rationale: Evaluating a client’s progress is not within the LPN's scope of practice.
⦁ Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus
Rationale: Establishing client goals based on data analysis is not within the LPN's scope of practice.
D. Assisting a client with crutch walking following knee replacement surgery
Rationale: Assisting a client with crutch walking is within the LPN's scope of practice.
63. A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
A. Focus on providing care that prevents life-threatening emergencies.
Rationale: The triage method in a disaster focuses on providing care to clients who have any immediate threat to life.
⦁ Reinforce discharge teaching to clients.
Rationale: In the event of a disaster, the nurse should focus on urgent client care. Discharge teaching should not be the nurse’s focus at this time.
⦁ Instruct the assistive personnel (AP) to focus on clients’ ADLs.
Rationale: The triage method in a disaster focuses on meeting critical needs, which does not include having the AP assist clients with ADLs.
⦁ Stock additional unit supplies.
Rationale: In a disaster, facilities implement the triage method, which calls for ancillary personnel to stock additional unit supplies for nursing personnel. The nurse should focus on urgent client care needs.
⦁ A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?
⦁ Application of antibiotic ointment to the arm of a client who has dermatitis
Rationale: A nurse cannot delegate a task that requires medication administration, such as application of antibiotic ointment to an infected area.
⦁ Obtaining medical history information from a stable client who is being admitted
Rationale: A nurse cannot delegate a task that requires assessment, such as obtaining information about a client’s medical history.
C. Monitoring vital signs of a client who had an appendectomy 12 hr ago
Rationale: Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an appropriate task for the AP because it does not involve assessment, specialized knowledge, or judgment.
D. Removal of the nasogastric tube of a client who has been receiving enteral feedings
Rationale:
A nurse cannot delegate a task that requires assessment and specialized skills or training, such as removing a nasogastric tube.
⦁ A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client’s dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take?
⦁ Change the client’s dressing.
Rationale: Changing the client’s dressing does not clarify the reason for lack of action by the assigned LPN.
⦁ Reassign the task to another nurse.
Rationale: Reassigning the task to another nurse does not clarify the reason for lack of action by the LPN.
C. Verify the LPN knows how to do a dressing change.
Rationale: The charge nurse should attempt to see the delegated task from the perspective of the individual being delegated to. This approach clarifies the reason for lack of action by the LPN.
D. Report the issue to the unit manager.
Rationale: Reporting the issue to the unit manager does not clarify the reason for lack of action by the LPN.
66. A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?
A. The state Nurse Practice Act
Rationale: The state Nurse Practice Act identifies the skill or education level needed by a nurse to complete a task, as well as indicating items that can and cannot be delegated from a legal perspective.
⦁ The National Association for Practical Nurse Education and Services
Rationale: This association promotes and defends the practice and education of practical nursing, but does not define tasks that can be delegated in each state.
⦁ The National Council of State Boards of Nursing Decision Tree
Rationale: The decision tree focuses on a step-by-step analysis that nurses can use to decide if a task can be delegated to assistive personnel.
⦁ The Omnibus Budget Reconciliation Act of 1987
Rationale: This act established regulations for the education and certification of assistive personnel.
⦁ A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?
A. "Delegation provides appropriate resources for the client."
Rationale: Delegation allows work to be done by others. It does not determine if the appropriate resources are being provided for clients.
B. "Delegation permits a designated individual to meet a goal on your behalf."
Rationale: Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.
C. "Delegation promotes discharge teaching activities for clients."
Rationale: Delegation allows work to be done by others. Teaching activities should not be delegated by nurses because they require specialized knowledge.
D. "Delegation decreases health care costs."
Rationale: Reducing the cost of health care can be a result of appropriate delegation, but this is not the purpose of delegation.
⦁ A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
⦁ A client who is 1 hr postoperative following a thyroidectomy
Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. A client immediately following a thyroidectomy would not be stable and would require the assessment of an RN.
⦁ A client who is 2 hr postoperative following an abdominal hysterectomy
Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. A client immediately following an abdominal hysterectomy would not be stable and would require the assessment of a RN.
C. A client who is 3 days postoperative following gastric bypass surgery
Rationale: The client’s physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. This client is 3 days postoperative and his condition would have stabilized by this time.
D. A client who is 3 days postoperative following a craniotomy
Rationale: The client’s multisystem involvement following a craniotomy is a consideration when assigning vital signs to an AP; this client requires assessment by the RN.
⦁ A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
⦁ Administration of an enema
Rationale: Administration of an enema is a task that is within the scope of practice for an AP.
⦁ Application of antiembolic stockings
Rationale: Application of antiembolic stockings is a task that is within the scope of practice for an AP.
C. Assessing a client’s sacrum for edema
Rationale: Assessment requires the nurse's specialized knowledge and cannot be delegated to an AP.
D. Assisting a client to cough and deep breathe
Rationale: Assisting a client to cough and deep breathe is a task that is within the scope of practice for an AP.
70. A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority task to delegate is the blood glucose monitoring for the client who has an insulin prescription. This task is time sensitive and should be completed first.
⦁ Apply a condom catheter to a client who is incontinent.
Rationale: Applying a condom catheter to an incontinent client is a nonurgent task. The client will need to have this task completed for comfort; however, there is another task that is the priority.
⦁ Feed a client who has bilateral casts due to upper arm fractures.
Rationale: Feeding a client who has bilateral casts is a nonurgent task. The client will need to have this task completed for nutritional needs; however, there is another task that is the priority.
⦁ Deliver a clean voided urine specimen to the laboratory.
Rationale: Delivering a specimen to the laboratory is a nonurgent task. This task will need to be completed for diagnostic purposes; however, there is another task that is the priority.
⦁ An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
A. Change the abdominal dressing.
Rationale: Changing the abdominal dressing requires assessment by the nurse; therefore, the nurse cannot delegate this task.
B. Obtain vital signs.
Rationale:
Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.
C. Palpate for possible bladder distention.
Rationale: Palpating the client’s bladder requires assessment by the nurse; therefore, the nurse cannot delegate this task.
D. Observe the incision site.
Rationale: Observing the incision site requires assessment of the client’s condition; therefore, the nurse cannot delegate this task.
72. A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
A. Attain a weight that is greater than the 75th percentile for age and height.
Rationale: When using Maslow’s hierarchy of needs, the nurse should determine the priority goal is to meet the physiological need for adequate nutrition. This means working with the client to attain an increase in weight.
⦁ Make positive statements about improvements in body image.
Rationale: Making positive statements about improvement in body image is important because the client needs to attain positive self-esteem; however, there is another goal that is the priority.
⦁ Feel in control of her behavior.
Rationale: Having the client feel she is in control of her behavior is important because the client needs to attain the goal of safety; however, there is another goal that is the priority.
⦁ Identify changes within the family unit that promote the client’s autonomy.
Rationale: The client needs to identify changes that promote autonomy because it is important for the client to attain the goal of love and belonging; however, there is another goal that is the priority.
⦁ A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take?
⦁ Review the LPN’s personnel file.
Rationale: Reviewing the LPN’s personnel file assists in understanding the LPN's educational background, but it does not address the clients' concerns.
⦁ Discuss the LPN’s behavior with other nurses on the unit.
Rationale: Discussing the LPN’s behavior with other nurses on the unit violates the LPN’s privacy and is not an action the nurse should take.
C. Talk with the clients who have reported the LPN’s lack of care.
Rationale: The charge nurse should investigate the allegations of misconduct to determine if disciplinary action is warranted.
D. Reassign some of the LPN’s client care to assistive personnel.
Rationale: Reassigning some of the LPN’s client care to others does not clarify the LPN’s lack of care. Attempting to work around the situation often causes resentment with other employees and does not address the clients' concerns.
⦁ A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program?
A. Proper foot care will be demonstrated to clients during the program.
Rationale: A goal is the desired result toward which effort is directed. Demonstrating proper foot care is an objective because it identifies how the goal will be met.
B. Clients will have a decreased incidence of foot amputations.
Rationale: A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program.
C. A facility will be reserved for the program.
Rationale: A goal is the desired result toward which effort is directed. Reserving a facility to ensure a location for the program is secure is an objective because it identifies how the goal will be met.
D. Handouts and teaching materials will be distributed at the program.
Rationale: A goal is the desired result toward which effort is directed. Handing out educational materials is an objective because it identifies how the goal will be met.
⦁ A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take?
A. Verify the AP’s educational preparation prior to delegating the task.
Rationale: The right person is one of the five rights of delegation. This AP is a participating team member; verification of the AP’s educational preparation would be done by the facility at the time of hiring.
B. Determine the time frame the AP should report the results.
Rationale: The right communication is one of the five rights of delegation. The nurse should communicate with the AP and provide direction as to when the AP should report the findings of the vital signs.
C. Observe the AP as she obtains the vital signs of each client.
Rationale:
The right level of supervision is one of the five rights of delegation. Obtaining vital signs is within the AP's scope of practice; therefore, the nurse does not need to directly observe the AP taking vital signs for each client.
D. Ask the AP to take the vital signs of the client returning from surgery first.
Rationale: The right circumstance is one of the five rights of delegation. The nurse should assess the client returning from surgery to ensure the client’s stability prior to delegating the AP to obtain the vital signs.
⦁ An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
⦁ The client who requires frequent ambulation
Rationale: An LPN can assume responsibility for this client. Ambulation can be delegated further to the AP.
⦁ The client who is in protective isolation
Rationale: An LPN can assume responsibility for a client who is in protective isolation. This client will be more time-consuming than others; therefore, the nurse should take this into consideration when making assignments.
C. The client who is actively dying and requires IV pain medication
Rationale: The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.
D. The client who is 3 days postoperative and requires a dressing change
Rationale: An LPN can assume responsibility for this client. Postoperative dressing changes are within the scope of practice for an LPN.
⦁ A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
⦁ Inform the staff member of her appraisal time for that day prior to change-of-shift report.
Rationale: The charge nurse should give the employee 2 to 3 days advance notice of the appraisal conference time so the staff member can be prepared for the interview.
⦁ Schedule the appraisal interview as early in the shift as possible.
Rationale: The charge nurse should schedule the appraisal interview at a time when it is not busy at work and when it is convenient for the staff member so she can have time to fully participate in the conference.
⦁ Provide a chair directly across the desk for the staff member to sit in.
Rationale:
The charge nurse should arrange the chairs so they are side by side to denote collegiality. Placing the chairs across from one another denotes a power status position.
D. Provide the staff member with a copy of the appraisal form in advance.
Rationale: The charge nurse should ensure the staff member knows the standards by which her work will be evaluated and that she has a copy of the appraisal form.
⦁ An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?
⦁ Agency policies for the LPN
Rationale: The nurse should consider the agency policies for the LPN to ensure delegation within the right circumstance; however, evidence-based practice indicates another criterion is the priority.
⦁ The documented experience level of the LPN
Rationale: The nurse should consider the documented experience of the LPN to ensure delegation to the right person; however, evidence-based practice indicates another criterion is the priority.
⦁ The documented skill level of the LPN
Rationale: The nurse should consider the documented skill level of the LPN to ensure delegation to the right person; however, evidence-based practice indicates another criterion is the priority.
D. State Nurse Practice Act for the LPN
Rationale: According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation.
79. A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)
A. Accompany a client who has depression to occupational therapy.
B. Assess a client who has hypomania for exhaustion.
C. Check the position of a client in soft wrist restraints.
D. Set limits with a client who has mania.
E. Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Rationale: Accompany a client who has depression to occupational therapy is correct. Accompanying a client to occupational therapy is within the scope of practice of an AP.
Assess a client who has hypomania for exhaustion is incorrect. Assessment of a client requires specialized knowledge and is an activity that cannot be delegated.
Check the position of a client in soft wrist restraints is correct. Checking the position of a client in soft wrist restraints is within the scope of practice of an AP. The
position can be reported to the nurse for follow-up.
Set limits with a client who has mania is incorrect. Implementing the plan of care requires specialized knowledge and is an activity that cannot be delegated.
Sit with a client who has alcohol use disorder and whose last drink was five days ago is correct. Sitting with a client is within the scope of practice of an AP. Any changes in the client can be reported to the nurse for follow-up.
⦁ A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
A. "The client’s family members have been present most of the day."
Rationale: The presence of family members is not a consideration in the decision to delegate tasks to the AP.
B. "The client’s blood pressure and pulse have been fluctuating throughout the day."
Rationale: Knowing the client and the stability of his condition is a criterion to consider when delegating to the AP. To promote client safety, the more stable clients should be chosen when delegating tasks to APs.
C. "The client discussed having prior thoughts of suicide."
Rationale: The client having a history of suicidal ideation is not a criterion to consider when delegating tasks to the AP.
D. "The client works in the hospital radiology department."
Rationale: The client being an employee is not a criterion to consider when delegating tasks to the AP.
81. A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities?
A. "I have my assignment and will start with room 1, then work my way to room 10."
Rationale: The AP’s statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized.
⦁ "I will give this client his meal tray first, as he is going early to physical therapy."
Rationale: This statement reflects the AP is establishing priorities and considering the time frame of the client leaving the floor early.
⦁ "After breakfast, I will pack the belongings of clients who will be discharged this morning."
Rationale: This statement reflects the AP is establishing priorities and recognizing this task can wait until after breakfast.
⦁ "I will start by providing partial baths before breakfast."
Rationale: This statement reflects the AP is establishing priorities and recognizing care that can be
initiated early with minimal time required before breakfast.
⦁ A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
⦁ "The nurse relinquishes accountability for client outcomes when care is delegated to an AP."
Rationale: The nurse who delegates a task retains accountability for client outcomes.
⦁ "The AP can provide client education about how to perform basic self-care to the client."
Rationale: Client education, along with assessment of client status and data interpretation, is the responsibility of the nurse.
C. "The nurse should consider the AP’s level of experience when making delegation decisions."
Rationale: When delegating a task, the nurse should delegate the task to the right person. The nurse should consider the AP’s job description, level of knowledge, and individual level of experience.
D. "The AP can re-delegate a task to another AP who has similar work experience."
Rationale: It is the nurse’s responsibility to make delegation decisions, including selecting the right person to whom the task can be delegated; therefore, the AP cannot re-delegate a task.
⦁ A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?
⦁ Right circumstances
Rationale: The right circumstances include delegating tasks that do not require independent nursing judgment.
⦁ Right communication
Rationale: The right communication includes providing clear explanations about the tasks, client outcomes, and when the delegate should report to the nurse.
⦁ Right person
Rationale: The right person means delegating to the individual who is competent and qualified.
D. Right supervision
Rationale: The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.
⦁ A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
⦁ A client who needs assistance with a bath
Rationale: Although the nurse should assist the client who needs assistance with a bath, when using the priority setting framework of urgent vs. nonurgent, this is not the client the nurse should care for first.
⦁ A client requesting a referral for home health services
Rationale: Although the nurse should help the client who needs a referral, when using the priority setting framework urgent vs. nonurgent, this is not the client the nurse should care for first.
C. A client asking about his PCA pump that contains morphine
Rationale: Clients who are administered morphine are at risk for respiratory distress. When using the urgent vs. nonurgent approach to client care, this is the client the nurse should care for first.
D. A client who has questions about his new prescription
Rationale: Although the nurse should answer the client’s questions about his new prescription, when using the priority setting framework of urgent vs. nonurgent, this is not the client the nurse should care for first.
⦁ At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
⦁ Providing postmortem care for a client
Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the LPN that can be completed by an AP.
⦁ Measuring a client’s I&O
Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the LPN that can be completed by an AP.
⦁ Obtaining a client’s weight
Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the LPN that can be completed by an AP.
D. Inserting a nasogastric tube for a client
Rationale: This is an appropriate task to assign to the LPN. It is not appropriate to assign this task to the AP.
⦁ A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
⦁ A child who is experiencing sickle cell crisis
Rationale: The nurse should not place these clients together. The child who is experiencing sickle cell
crisis requires rest and pain management, and the child who is postoperative from an appendectomy requires frequent assessments and interventions.
⦁ A child who has streptococcal pharyngitis
Rationale: The nurse should not place these clients together. A child who has streptococcal pharyngitis requires contact precautions and a private room.
⦁ A child who has a head injury
Rationale: The nurse should not place these clients together. The child who has a head injury requires a quiet, low stimulus environment, and the child who is postoperative from an appendectomy requires frequent assessments and interventions.
D. A child who has a new diagnosis of type 1 diabetes mellitus
Rationale: The nurse should place these clients together. It is appropriate because the child who has diabetes requires monitoring and teaching and the child who is postoperative from an appendectomy requires frequent assessments and interventions.
⦁ An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
⦁ A client who has terminal end-stage renal disease
Rationale: The nurse who floats to another unit must have the skills to provide safe care to clients. This client is unstable and his condition could change rapidly. This is not an appropriate assignment for the RN.
⦁ A client who has acute pancreatitis
Rationale: The nurse who floats to another unit must have the skills to provide safe care to clients. This client is unstable and his condition could change rapidly. This is not an appropriate assignment for the RN.
C. A client who is one-day postoperative following a total abdominal hysterectomy
Rationale: The nurse who floats to another unit must have the skills to provide safe care to clients. This client is stable. This is an appropriate assignment for the RN.
D. A client who had a stroke and is to be admitted
Rationale: The nurse who floats to another unit must have the skills to provide safe care to clients. This client is expected to be unstable. This is not an appropriate assignment for the RN.
⦁ A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
A. A school-age child who has diabetes mellitus and requires blood glucose monitoring
Rationale: The nurse should provide care to a child who requires blood glucose monitoring; however, the
nurse should assess another client first.
B. An infant who has pertussis and is receiving oxygen via nasal cannula
Rationale: Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this infant should be assessed first because the infant has a compromised airway and requires oxygen.
C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
Rationale: The nurse should assess the adolescent who was admitted in sickle cell crisis; however, since this client is stable and ready for discharge, the nurse should assess another client first.
D. A toddler who has both arms in casts and needs to be fed his breakfast
Rationale: The nurse should feed the toddler; however, the nurse should assess another client first.
⦁ A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?
⦁ Take the specimen to the laboratory.
Rationale: Taking the specimen to the laboratory is avoiding confrontation. This action does not determine the underlying problem.
⦁ Report the AP to the charge nurse.
Rationale: Reporting the AP to the charge nurse does not clarify the reason for the AP’s lack of action.
This action does not determine the underlying problem.
⦁ Complete an incident report.
Rationale: An incident report is required when there is an accident or unusual occurrence. It is not required in this situation.
D. Ask the AP about her concerns with the assignment.
Rationale: Reviewing the incident with the AP allows the nurse to understand the delegated task from the AP’s perspective. The nurse should attempt to determine the underlying problem the AP has with the assignment.
⦁ A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?
⦁ Transporting a client who experienced a stroke 72 hr ago to the radiology department
Rationale: APs are trained on how to use transfer techniques; therefore, this task is within their range of function and does not have to be reassigned.
⦁ Providing a back rub to a client who has right-sided paralysis
Rationale: APs are trained on how to properly turn a client and perform a back rub; therefore, this task is
within their range of function and does not have to be reassigned.
C. Removing and cleaning the cannula of a client who has a new tracheostomy
Rationale: Removing and cleaning the cannula of a client who has a new tracheostomy requires use of the nursing process, specialized knowledge, and clinical judgment; therefore, this task should be reassigned to a licensed nurse.
D. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
Rationale: APs are trained on oral hygiene techniques; therefore, this task is within their range of function and does not have to be reassigned.
⦁ A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly?
A. Provide a written procedure for the use of the device for the staff to review.
Rationale: This strategy might be useful for learners who wish to prepare beforehand or check a detail afterward, but it does not ensure the staff can use the device correctly.
B. Demonstrate using the device and observe the staff returning the demonstration.
Rationale: The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.
C. Remind the staff to review the procedure manual prior to using the new pump.
Rationale: This strategy might be useful for learners who wish to accept responsibility for learning, but it does not ensure the staff can use the device correctly.
D. Identify the differences and new features of the device in a written brochure.
Rationale: This strategy might be useful for learners who wish to accept responsibility for learning, but it does not ensure the staff can use the device correctly.
92. A nurse enters a client’s room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
A. Call the emergency response team.
Rationale: Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility’s protocol for enacting the emergency response procedure.
⦁ Seek immediate help from the risk manager.
Rationale: The nurse does not have time to wait for a response from the risk manager. The nurse should follow the facility’s protocol for this type of situation.
⦁ Call the provider for a stat DNR order.
Rationale: The nurse should follow the facility’s protocol for this type of situation.
⦁ Respect the family’s wishes and do nothing.
Rationale: The nurse should follow the facility’s protocol for this type of situation. Without a DNR order, the nurse cannot follow the family’s wishes.
93. A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the
medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
A. A client who has a lumbosacral spinal tumor
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. The client who has a lumbosacral spinal tumor is not at risk for dysphagia; therefore, the nurse should delegate meal assistance to the AP for this client.
⦁ A client who has Guillain-Barre syndrome
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A client who has Guillain-Barre syndrome is at risk for aspiration during swallowing; therefore, it is unsafe for the nurse to delegate this task to the AP.
⦁ A client who has amyotrophic lateral sclerosis (ALS)
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A client who has ALS is at risk for aspiration during swallowing; therefore, it is unsafe for the nurse to delegate this task to the AP.
⦁ A client who has systemic sclerosis
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A client who has systemic sclerosis is at risk for aspiration during swallowing; therefore, it is unsafe for the nurse to delegate this task to the AP.
94. A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement?
A. Sit in front of the group for the meeting and then stand for the announcement.
Rationale: The weight of a message increases when the sender stands.
⦁ Cross her arms over her chest when beginning the announcement.
Rationale: Crossing the arms over the chest suggests defensiveness or aggressiveness and will detract from the importance of the message the nurse is sending.
⦁ Stare at the people the announcement will affect the most.
Rationale:
Staring impedes connecting with others emotionally and might change the impact of the message the nurse is sending.
⦁ Lean gently over the back of a chair sitting to one side of the room when making the announcement.
Rationale: Slouching or non-erect posture suggests indifference and changes the impact of the message the nurse is sending.
⦁ A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?
⦁ "Tell me why you feel hopeless."
Rationale: Asking why questions is nontherapeutic and the client may not be able to put her feelings of hopelessness into words.
⦁ "I am sure these feelings will pass once you go home."
Rationale: This statement is false reassurance and does not encourage the client to talk about her feelings.
⦁ "If I were you, I would ask for a referral to hospice care."
Rationale: Although referral to hospice may be helpful for the client, the nurse should avoid giving the client her personal opinion.
D. "Tell me what you understand about your illness."
Rationale: The nurse should use this statement to encourage the client to express her feelings and concerns.
⦁ A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form?
⦁ Extended family
Rationale: An extended family includes aunts, uncles, grandparents, and cousins.
⦁ Blended family
Rationale: A blended family occurs when two families are brought together to create a new family form.
C. Nuclear family
Rationale: A nuclear family consists of parents and offspring.
D. Intergenerational family
Rationale: An intergenerational family consists of a family form of two or more generations, such as grandparents caring for children or adult children living with their parents.
⦁ A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
A. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
Rationale: Gastric aspirate that is green with a pH of 5.3 for a client who has a nasogastric tube for decompression is nonurgent because it is an expected finding; therefore, this client should not be assessed first.
B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Rationale: After removal of an indwelling urinary catheter, the client should void within 4 hr. If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore, when using the priority-setting framework of urgent vs. nonurgent, this client should be assessed first because he has not voided for 5 hr.
C. A client who has COPD and the capillary refill time on both hands is 4 seconds
Rationale: A capillary refill time of 4 seconds is nonurgent for a client who has COPD because it is an expected finding; therefore, this client should not be assessed first.
D. A client who has late-stage cirrhosis and whose breath has a fruity odor
Rationale: Breath that has a fruity or musty odor, known as fetor hepaticas, is nonurgent because it is an expected finding for a client who has late-stage cirrhosis; therefore, this client should not be assessed first.
⦁ A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?
⦁ Assess the AP’s ability to follow the client’s teaching plan.
Rationale: The nurse cannot delegate teaching to an AP; therefore, the nurse does not need to assess the AP’s ability to follow the client's teaching plan.
⦁ Determine the social skills of the AP.
Rationale: Knowing the AP's skills is important when planning to delegate a task; however, the social skills of the AP are not essential when planning to delegate a task.
⦁ Evaluate the ability of the AP to work with peers.
Rationale: Knowing the AP's skills is important when planning to delegate a task; however, the ability of the AP to work with peers is not essential when planning to delegate a task.
D. Provide a clear description of the task to the AP.
Rationale: Providing a clear, concise description of the task, as well as the expected outcome, is essential when planning to delegate a task to the AP.
⦁ A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)
⦁ Establish that the client is able to pay for the surgical procedure.
⦁ Explain the surgical procedure to the client.
C. Validate the signature is authentic.
D. Verify the client understands the surgical procedure.
E. Confirm that the consent is voluntary.
Rationale: Establish that the client is able to pay for the surgical procedure is incorrect. The client's ability to pay for the procedure is not required prior to obtaining an informed consent.
Explain the surgical procedure to the client is incorrect. It is the surgeon's responsibility to explain the procedure to the client.
Validate the signature is authentic is correct. The nurse must validate the signature on the consent is made by the client or the client's legal guardian.
Verify that the client understands the surgical procedure is correct. The nurse should verify the client understands the procedure and the risks.
Confirm that the consent is voluntary is correct. The nurse should confirm the client is giving voluntary consent without coercion.
⦁ nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
⦁ Assault
Rationale: Assault is the act of verbally threatening a client. A nurse who verbally threatens to give a medication to a client without the client’s consent is committing assault.
⦁ False imprisonment
Rationale: False imprisonment is detaining a client against her will without legal warrant. A nurse who administers a chemical restraint without the client’s consent is committing false imprisonment.
⦁ Negligence
Rationale: Negligence is a breach of duty that results in harm to the client. A nurse who administers an incorrect medication to a client is committing professional negligence.
D. Battery
Rationale: Battery is physical contact without the client’s consent. Administering a medication against a client’s wishes is an example of battery.
101.A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
A. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
Rationale: Professional negligence is performing practice below the expected standard of care. It can be an act of omission, which is the failure to perform an act that a reasonable prudent person, under similar circumstances, would do. A reasonably prudent nurse would notify the provider of the neurovascular finding immediately.
⦁ A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
Rationale: Battery is physical contact without the client’s consent. Administering a medication against a client’s wishes is an example of battery.
⦁ A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
Rationale: False imprisonment is the act of detaining a client against his will without legal warrant.
⦁ A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Rationale: Assault is the act of verbally threatening a client.
102.A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness?
A. "I feel as though I met the standard of care. Would you tell me more about your concerns?"
Rationale: Communicating assertively is expressing thoughts in an open, honest, and direct manner that demonstrates respect for self and others. The use of "I" statements, maintaining eye contact, and congruent verbal and facial expressions are all components of assertiveness skills. The nurse demonstrates respect for the opinion of the other nurse by asking for feedback and the reason for the concerns.
⦁ "You shouldn't make accusations. Your nursing care doesn't always set a good example."
Rationale: This response is aggressive because the nurse is directly insulting the other nurse.
⦁ "I am at a loss for words. I always do my best to give good care to my clients."
Rationale: This response is submissive because the nurse is accepting the opinion of the other nurse without regard to his own opinions.
⦁ "What do you have against me? It must be something or you wouldn't be criticizing my care."
Rationale: This response is aggressive because the nurse is disregarding and insulting the other nurse.
⦁ charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
⦁ Avoiding
Rationale: The charge nurse did not display avoiding, which is not to acknowledge or try to resolve the conflict.
⦁ Competing
Rationale: The charge nurse did not display competing, which is when one person makes a quick or unpopular decision at the expense of another.
⦁ Compromising
Rationale: The charge nurse did not display compromising, which is when all parties involved are willing to give up something in the resolution of the conflict.
D. Cooperating
Rationale: The charge nurse displayed cooperating, which is the resolution of the conflict by sacrificing.
In this situation, it allowed both staff nurses to get what they wanted.
⦁ nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
⦁ "I should wait to empty my client’s drainable colostomy until it is three-fourths full."
Rationale: The nurse should empty the client’s drainable colostomy when it is one-third to one-half full. If the nurse waits until it is three-fourths full, the skin seal can break and cause skin breakdown. Therefore, it is not cost-effective for the nurse to plan to take this action.
⦁ "I should delegate providing closed irrigation to the assistive personnel (AP)."
Rationale: It is cost-effective to delegate basic tasks to the AP, but the nurse should not delegate a skill requiring the use of sterile technique to the AP.
C. "I should encourage clients to receive an annual flu immunization."
Rationale: Cost containment is the delivery of effective and efficient care. Cost is maintained without loss of quality. The nurse should encourage clients to receive an annual flu immunization to prevent the need for treatment and hospitalization necessary with influenza.
D. "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care."
Rationale: The nurse should recommend that clients who have a tracheostomy older than 1 month use clean technique to perform tracheostomy care.
⦁ nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the
following as a triage officer during the time of a disaster?
⦁ Members of the Federal Emergency Management Agency (FEMA)
Rationale: FEMA is responsible for coordinating national disaster response efforts when local and state resources are overwhelmed.
⦁ Responding law enforcement officers
Rationale: Law enforcement officers are not able to make the appropriate medical assessments to perform triage.
⦁ Representatives from the American Red Cross
Rationale: Representatives from the American Red Cross are often lay volunteers. Their responsibility is to provide assistance to individuals in need following a disaster.
D. Nurses and other emergency medical personnel
Rationale: Nurses and other emergency personnel such as physicians, EMTs, and paramedics are responsible for performing triage duties.
106.A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?
A. "Disaster drills should be held on a regular basis."
Rationale: Hospitals should perform disaster drills on a routine basis to ensure effective response in the event of a disaster.
⦁ "An actual disaster cannot take the place of a disaster drill."
Rationale: A disaster drill can be replaced by participation in an actual disaster.
⦁ "A staff nurse can function as the incident commander."
Rationale: The incident commander should be a hospital administrator or nursing supervisor who can implement the disaster plan.
⦁ "A physician must triage victims of a disaster in the emergency department."
Rationale: Emergency department nurses perform triage during disasters.
⦁ charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)?
⦁ "HICS ensures that necessary antibiotics and antidotes are available."
Rationale: The Strategic National Stockpile, rather than HICS, ensures that antibiotics and antidotes are available during a public health emergency.
⦁ "HICS is focused on having multidisciplinary responders available."
Rationale: The Metropolitan Medical Response System, rather than HICS, is focused on having multidisciplinary responders available during an emergency.
C. "HICS identifies facility responsibilities and channels of reporting."
Rationale: HICS identifies responsibilities and channels of reporting within the facility to provide a uniform response plan among facilities.
D. "HICS provides additional responders when needs exceed the ability of local or state agencies."
Rationale: The Commissioned Corps, rather than HICS, provides additional health care professionals when the needs exceed the ability of local or state agencies during an emergency.
⦁ nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents?
⦁ Chemical
Rationale: The emergency department nurse should be prepared for a client following exposure to chemical agents; however, this type of agent is not referred to as a "dirty bomb."
⦁ Anthrax
Rationale: Anthrax is a bacterium that is used in bioterrorism. It is not included in a "dirty bomb."
C. Radiologic
Rationale: A "dirty bomb" combines radiologic agents with an explosive device, resulting in immediate effects of radiation exposure.
D. Sarin
Rationale: Sarin is a gas that affects the central nervous system. It is not included in a "dirty bomb."
⦁ nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?
A. "I had strep throat about one year ago."
Rationale: Having streptococcal infection of the throat is not a contraindication for taking glyburide.
B. "I plan to continue nursing my baby until he is at least a year old."
Rationale: Glyburide is a sulfonylurea that is used to treat type 2 diabetes, but it is contraindicated during pregnancy and breastfeeding.
C. "I got my flu shot at the pharmacy two weeks ago."
Rationale:
Getting an immunization for influenza is not a contraindication for taking glyburide.
D. "I am allergic to shellfish."
Rationale: Although an allergy to shellfish may be a contraindication to the use of contrast media in some diagnostic tests, it is not a contraindication for taking glyburide.
⦁ charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?
⦁ Assess the problem.
Rationale: During the unfreezing stage, the charge nurse should assess the problem.
⦁ Use tactics to alert staff nurses that a change is needed.
Rationale: During the unfreezing stage, the charge nurse should make the staff nurses aware that a change is needed.
⦁ Evaluate the effectiveness of the change.
Rationale: During the refreeze stage, the charge nurse should evaluate the effectiveness of the change.
D. Set a target date.
Rationale: During the moving stage, the charge nurse should develop the plan for change and set the target date.
⦁ nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict?
⦁ Nurses on the unit disagree about what time of day daily client weights should be obtained
Rationale: This is an example of intergroup conflict.
⦁ A nurse is uncertain about joining a professional nursing organization
Rationale: This is an example of intrapersonal conflict.
⦁ A nurse who just lost his spouse does not want to be assigned to care for a terminally ill client
Rationale: This is an example of intrapersonal conflict.
D. An experienced nurse is uncivil to a newly licensed nurse
Rationale: Incivility and bullying are examples of interpersonal conflict. Interpersonal conflict arises from differing goals and value systems.
⦁ charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?
⦁ "You should think about how you make others feel when you lose your temper."
Rationale: This statement is inflammatory and will likely make the provider defensive.
⦁ "I will help you with this procedure instead of the staff nurse."
Rationale: When using this approach, the charge nurse is avoiding the conflict.
C. "It must be very frustrating when you don't have want you need to perform the procedure."
Rationale: The charge nurse is acknowledging the provider's frustration when making this statement.
This can lead to resolution of the conflict.
D. "If you let us know ahead of time that you plan to perform a procedure, we could do a better job of having the supplies available."
Rationale: This statement by the charge nurse avoids the problem and places blame on the provider.
⦁ nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make?
⦁ "I will ask the nursing supervisor to obtain the medical records for you."
Rationale: The nursing supervisor is not responsible to obtain the medical records for a client's family.
All health care workers must adhere to the Health Insurance Portability and Accountability Act (HIPAA) to avoid violating client confidentiality.
⦁ "The health care provider will share this information with you."
Rationale: The health care provider does not always have the authority to share a client's health care information. All health care workers must adhere to the Health Insurance Portability and Accountability Act (HIPAA) to avoid violating client confidentiality.
⦁ "The ethics committee will need to approve this request for you."
Rationale: The ethics committee is not responsible for obtaining the medical records for a client’s family. All health care workers must adhere to the Health Insurance Portability and Accountability Act (HIPAA) to avoid violating client confidentiality.
D. "The client must provide permission to share the records with you."
Rationale: Client information is shared only with individuals involved directly in the client's care. The client must provide permission for the family to access protected health information.
⦁ nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
⦁ A client who is a 1 day postpartum after a late term miscarriage
Rationale:
A client who is 1 day postpartum after a late term miscarriage is stable. Therefore, there is another client the nurse should assess first.
⦁ A client who had a bilateral tubal ligation 12 hr previously
Rationale: A client who had a bilateral tubal ligation 12 hr previously is stable. Therefore, there is another client the nurse should assess first.
⦁ A client who is 4 days postpartum and has mastitis
Rationale: A client who is 4 days postpartum and has mastitis is stable. Therefore, there is another client the nurse should assess first.
D. A client admitted 1 hr ago for an ectopic pregnancy
Rationale: A client who has an ectopic pregnancy is unstable. The client is at risk for rupture of the fallopian tube, hemorrhage, and shock. Nursing care requires frequent monitoring every 15 min, IV access for fluid resuscitation. The client may also require blood transfusions, oxygen, and pain management. Therefore this client is the highest priority.
⦁ nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
A. Taking a telephone prescription about a client who is to be transferred from PACU
Rationale: Taking a telephone prescription about a client who is to be transferred from PACU is nonurgent, because the client who is in the PACU is stable. This client is ready for discharge from the PACU, therefore he is stable and in a safe care environment. Therefore, another action is the priority.
B. Assessing a client who experiences unilateral calf pain when ambulating
Rationale: When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is assessing a client who has manifestations of a deep vein thrombosis, which can lead to pulmonary embolus. The nurse should assess this client and report the findings immediately to the provider.
C. Reinforcing a client's dressing for the surgical site of an above-the-knee amputation
Rationale: Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation is nonurgent. This is a routine procedure for this client. There is another action that is the nurse’s priority.
D. Reassuring the partner of a client who sustained a closed head injury
Rationale: Reassuring the partner of a client who sustained a closed head injury is nonurgent because it is an expected action for this client. Therefore, another action is the nurse’s priority.
⦁ nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
⦁ A client who has a splinted open fracture of left medial malleolus
Rationale:
A client who has a splinted open fracture is stable because care can wait for 30 min to 2 hr in a mass casualty situation. This client is triaged as urgent, or yellow-tagged, and has a major injury that should be assessed as a second priority. Therefore, there is another client the nurse should assess first.
⦁ A client who has a massive head injury and is experiencing seizures
Rationale: A client who has a massive head injury is triaged as expectant, because in a mass casualty situation, this injury is severe and likely incompatible with life. Clients who are considered expectant will be allowed to die and are given the lowest priority to assess. Therefore, the client will be given comfort measures and treated if care is available after initial triage and treatment of the mass casualty situation is complete.
C. A client who has severe respiratory stridor and a deviated trachea
Rationale: A client who has severe respiratory stridor and a deviated trachea is unstable. This client is triaged as emergent, and requires immediate attention to survive. This client has manifestations of a tension pneumothorax and airway obstruction. Therefore, this client is the highest priority for the nurse to assess.
D. A client who has a small circular partial-thickness burn of the left calf
Rationale: A client who has a small partial-thickness burn is stable because care can wait for 2 hr or more in a mass casualty situation. This client is triaged as nonurgent, or green-tagged, and has a minor injury. Nonurgent clients have minor injuries that are not life-threatening and do not require priority attention. Therefore, there is another client the nurse should assess first.
117.A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
A. Ambulate an older adult client who has hypertension.
⦁ Provide discharge instructions for a client who has a new skin graft.
⦁ Perform an admission assessment on a client.
⦁ Check a blood product with another nurse prior to administration.
E. Weigh a client who has heart failure.
Rationale: Ambulate an older adult client who has hypertension is correct. An AP can ambulate an older adult client who has hypertension.
Provide discharge instructions for a client who has a new skin graft is incorrect. An RN should provide discharge teaching for a client.
Perform an admission assessment on a client is incorrect. An RN should perform an admission assessment on a client.
Check a blood product with another nurse prior to administration is incorrect. Two RNs or one RN and one licensed practical nurse (LPN) should check a blood product before administration.
Weighing a client who has heart failure is correct. An AP can weigh a client who is stable.
⦁ nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
A. Notify hospital security.
Rationale: The nurse should notify hospital security if the man is not authorized to be in possession of the client's medical record to protect the client's confidentiality. However, there is another action the nurse should take first. It is premature to call hospital security until the nurse knows more about the situation. The nurse should notify hospital security If the man is not authorized to be in possession of the medical record or there is any concern for the safety of staff or clients.
B. Approach the man and ask why he is making copies.
Rationale: The first action the nurse should take using the nursing process is to assess the situation to determine whether this man is authorized to be in possession of the client's medical record to protect the client's confidentiality. Making copies from a client's medical record is allowed under specific circumstances. It is important to act in a timely fashion to protect the client's medical information. The nurse should approach the individual in a nonthreatening way to inquire about the copies being made.
C. Inform the nursing supervisor.
Rationale: The nurse should inform the nursing supervisor if the man is not authorized to be in possession of the client’s medical record to protect the client's confidentiality. However, there is another action the nurse should take first.
D. Report the observation to the nurse caring for that client.
Rationale: The nurse should report the observation to the nurse caring for that client if the man is not authorized to be in possession of the client's medical record to alert the client of a possible breach in confidentiality. However, there is another action the nurse should take first.
⦁ nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
A. Establish a benchmark to identify a standard of performance.
Rationale: A benchmark measures the practices of an organization against a best–performing organization in order to develop improvement of performance. It is used as a tool to determine the desired standard of performance.
B. Compare the number of medication errors before and after the action was implemented.
Rationale: Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions.
C. Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Rationale: A questionnaire that determines staff satisfaction can provide a means of communication regarding the new practice, but it does not measure the success of the new measures.
D. Conduct a study about the time and money costs of implementing the change.
Rationale: A study about the time and money costs of the effort is useful for comparing the success of the changes to the cost required to make them. However, this will not measure how successful the changes were in reducing medication errors.
120.A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
A. "Do not adjust the oxygen flow rate."
Rationale: The nurse should instruct the client not to adjust the oxygen flow rate to ensure that the client receives the prescribed rate.
⦁ "Check your oxygen equipment once each week."
Rationale: The client or caregiver should check the oxygen equipment daily to ensure proper functioning.
⦁ "Store unused oxygen tanks horizontally."
Rationale: Store unused oxygen tanks upright to prevent injury to the client or the client's home.
⦁ "Use wool blankets on your bed."
Rationale: The client should avoid wool or material that can generate static electricity to reduce the risk for a fire.
⦁ nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
⦁ "I do not know how to make the remote control work."
Rationale: It is not the responsibility of the PN to instruct the client about how to use the remote control.
Supervision includes providing clear directions and expectations, monitoring performance, providing feedback and constructive criticism, intervening when necessary, and evaluating whether client needs were met.
⦁ "Do you know when I will be going home?"
Rationale: The nurse might not know the answer to this question, and it is not an expectation of the PN to know the answer to this question.
⦁ "My dressing was changed earlier this morning."
Rationale: The PN should change the client's dressing as prescribed. The RN should follow up to ensure that this was done as prescribed and in a timely manner. The RN should inspect the dressing and evaluate the condition of the wound.
D. "I have not received any of my medications today."
Rationale: Failure to receive prescribed medications in a timely manner can have a negative effect on
client outcomes. The nurse should immediately follow up with the PN to determine if medications have been administered and, if not, to learn why. It is possible that the client does not remember receiving medications or that no medications were been prescribed as of this time. Effective supervision requires that any issue that can negatively impact client care is followed up on immediately.
⦁ charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment?
A. Ask each nurse to read the procedure and sign a form acknowledging competency.
Rationale: The charge nurse should ask each nurse to read the procedure and sign a form to acknowledge competency. However, evidenced-based practice indicates another action better evaluates competency with a psychomotor skill.
B. Allow time during the workday when each nurse can demonstrate proficiency.
Rationale: According to evidenced-based practice, the best action to evaluate competency with a psychomotor skill is by return demonstration. Ensuring that each nurse knows how to use the equipment through return demonstration is the best way to measure correct use of the new equipment. Prior to full implementation of any new equipment, the supervisory team should allow time for training and proficiency checks to ensure that client care is not compromised.
C. Require each nurse to take a written examination about the new equipment.
Rationale: The nurse should ask each nurse to take a written examination about the new equipment to acknowledge competency. However, evidenced-based practice indicates another action better evaluates competency with a psychomotor skill.
D. Verbally question the staff about the new equipment.
Rationale: The nurse should verbally question the staff about the new equipment to acknowledge competency. However, evidenced-based practice indicates another action better evaluates competency with a psychomotor skill.
123.A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?
A. The nurse separates the client's labia with her dominant hand.
Rationale: The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.
⦁ The nurse coats the indwelling urinary catheter with lubricant.
Rationale: The nurse should coat the catheter tip with a water-soluble lubricant to reduce the risk for tissue trauma and discomfort.
⦁ The nurse provides perineal care prior to inserting the urinary catheter.
Rationale: The nurse should provide perineal care prior to inserting the urinary catheter. Providing perineal care to the client prior to insertion of the urinary catheter allows the nurse time to visualize the meatus and to reduce the risk of introducing bacteria into the urinary tract.
⦁ The nurse applies the sterile drape prior to inserting the urinary catheter.
Rationale: The nurse should apply a sterile drape and should don sterile gloves prior to inserting the urinary catheter to reduce the risk of introducing bacteria into the urinary tract.
⦁ nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
⦁ Implement a resolution.
Rationale: The nurse should implement a solution to resolve the conflict. However, there is another action the nurse should take first.
⦁ Brainstorm solutions.
Rationale: The nurse should brainstorm solutions to resolve the conflict. However, there is another action the nurse should take first.
C. Identify the problem.
Rationale: The first action the nurse should take using the nursing process is to assess the situation and identify the problem so that a solution is found.
D. Evaluate the results.
Rationale: The nurse should evaluate the solution to determine if the problem has been resolved.
However, there is another action the nurse should take first.
⦁ nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
⦁ Perform wound irrigation for a client.
Rationale: The AP can change simple dressings, but the nurse should perform wound irrigation because it requires sterile technique and assessment skills.
⦁ Evaluate pain relief for a client following the administration of a pain medication.
Rationale: The RN should assess and interpret data and evaluate a client following the implementation of care.
C. Measure and record intake and output for a client.
Rationale: The AP can measure and record intake and output (I&O) for a client. It is the nurse's
responsibility to review the recorded results and respond as necessary.
D. Teach a client about low-sodium foods.
Rationale: Food selections require teaching, assessment, and evaluation. A nurse should teach the client about making selections for a prescribed diet.
⦁ nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?
⦁ "It is time to sign the consent so your treatment can begin."
Rationale: The nurse should verify the client has received enough information about the procedure before witnessing informed consent. Clients have the right to refuse to sign a consent form and should not be told that they must or should sign a consent form.
⦁ "I would not have this type of surgery if I were you."
Rationale: The nurse should not share personal opinions about treatment options. The role of the nurse is to advocate for the client and provide education.
C. "Have you discussed other treatments with your provider?"
Rationale: The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure.
D. "I can inform the surgeon you do not want the surgery."
Rationale: Although the client has the right to refuse any type of treatment, he has not stated he does not want the surgery. The client has indicated he is unclear about treatment options and requires further information before informed consent is obtained.
⦁ nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?
⦁ Counsel the provider to determine the cause of the substance abuse.
Rationale: The responsibility of the nurse is to protect clients from injury. It is not the responsibility of the nurse to counsel the provider.
⦁ Encourage clients to change to a different provider.
Rationale: Encouraging clients to change services based on assumptions is defamation and could result injury to the reputation of the provider. The nurse could be sued for this action.
⦁ Inform the state medical board for an immediate investigation.
Rationale: It is the responsibility of hospital management and administration to follow up with any state licensure boards in cases of impairment or client negligence or harm.
D. Notify the nursing supervisor of the concerns.
Rationale: The nurse should notify hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse.
⦁ home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
⦁ Hospice care
Rationale: Hospice care focuses on palliative care and not curative care. The purpose is to provide support to the client in the final phase of an illness with a focus on comfort measures to reduce pain and suffering in the home or in a hospice center.
⦁ Restorative care
Rationale: Restorative care assists the client in achieving and maintaining the highest possible level of function. This plan of care helps the client to achieve health goals and prevent deterioration by promoting independence and mobility. The systematic approach includes services such as physical therapy, occupational therapy, speech therapy, and cardiac rehabilitation.
⦁ Mental health care
Rationale: Mental health care is provided by psychiatrists, psychologists, counselors, or social workers to evaluate mental health as well as to teach adaptive coping strategies and communication skills to manage mental health disorders.
D. Respite care
Rationale: Respite care provides temporary relief for caregivers who care for disabled or chronically ill clients. The respite allows the caregiver an opportunity to complete errands and personal business, as well as time to recover both emotionally and physically.
129.A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?
A. Encourage the client to verbalize questions.
Rationale: The nurse acts as a client advocate by providing the client with information needed to make informed decisions regarding care.
⦁ Insist the client take prescribed medications.
Rationale: Forcing or insisting that the client take the medication does not respect the client's right to an informed decision. The client has a right to information regarding their treatment and management of care.
⦁ Inform the client that the medication is the same as taken at home.
Rationale:
In this response, the nurse does not encourage the client to ask questions regarding the medications prescribed. The nurse, as a client advocate, should teach the client about each medication, including its expected effects and adverse effects.
⦁ Tell the client that refusal of the medication is considered noncompliance.
Rationale: In this response, the nurse does not support the client or demonstrate client advocacy. The client has a right to refuse care and treatment after receiving full disclosure of information regarding prescribed medication, such as its action, expected effects, and adverse effects.
⦁ nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
A. A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache
Rationale: Crohn’s disease is a chronic disorder and a serum calcium level of 10 mg/dL is within the expected reference range. Although the nurse should address the needs of this client, there is another client the nurse should assess first.
B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
Rationale: When using the acute vs. chronic approach to client care, the nurse should first assess the client who has diabetes and takes glipizide. An adverse effect of glipizide is hypoglycemia and a blood glucose level of 68 mg/dL is below the expected reference range; therefore, this is the client the nurse should assess first.
C. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
Rationale: Expected findings for a client who has acute glomerulonephritis include hematuria, decreased urine output, and proteinuria. Although the nurse should address the needs of this client, there is another client the nurse should assess first.
D. A client who was administered acyclovir for cellulitis reports pain in the affected leg
Rationale: Expected findings for a client who has cellulitis include pain, erythema, and warmth in the affected area. Although the nurse should address the needs of this client, there is another client the nurse should assess first.
⦁ nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
⦁ Raise all side rails on the client's bed.
⦁ Obtain a prescription to restrain the client PRN.
C. Check on the client hourly.
D. Instruct the client in the use of the call light.
E. Apply an ambulation alarm to the client's leg.
Rationale: Raise all side rails on the client's bed is incorrect. Raising all side rails is considered a restraint. For a client who is disoriented, the risk for injury is greater with all side rails of the bed raised. If the client attempts to get out of bed, she may try to climb over the side rail or climb out at the foot of the bed. The nurse should place the bed in the lowest position.
Obtain a prescription to restrain the client PRN is incorrect. Restraints are not prescribed PRN. Written restraint prescriptions are for a specific event and must have start and end times. Temporary restraints might be needed for clients who are confused, disoriented, repeatedly fall, or try to remove medical devices.
Check on the client hourly is correct. Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach.
Instruct the client about the use of the call light is correct. Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use.
Apply an ambulation alarm to the client's leg is correct. The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.
⦁ nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse’s priority?
⦁ A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
Rationale: Both blood glucose levels are within the expected reference range. This client is stable; therefore, he is not the nurse’s priority.
⦁ A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
Rationale: A change in the color of wound drainage from sanguineous to serosanguineous is an expected finding for a client who is 24 hr postoperative from surgery. Therefore, this client is not the nurse’s priority.
⦁ A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
Rationale: The nurse should ask the client to rate his pain on a scale of 0 to 10 and provide care to manage the client’s pain. However, this client is not the nurse’s priority.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Rationale: A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse’s priority.
⦁ nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the
following actions by the nurse indicates the nurse manager should intervene?
⦁ The nurse uses clean gloves when discontinuing a client’s intravenous infusion.
Rationale: The nurse should wear clean gloves when performing the procedure because they reduce the risk of transferring microorganisms from the client.
⦁ The nurse empties a client’s drainable colostomy pouch when it is one-third full.
Rationale: The nurse should empty the client’s colostomy pouch when it is one-third to one-half full. If the pouch becomes too heavy, it can cause the seal on the pouch to break the skin and subsequently expose the area around the ostomy to stool.
⦁ The nurse uses the client’s telephone number as one form of identification when administering medications to a client.
Rationale: The nurse should use two forms of identification prior to administering medications to a client. Acceptable forms of identification include telephone number, as well as the client’s name and birthdate.
D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
Rationale: The nurse should avoid reaching across a sterile field; therefore, the nurse should place the sterile tray on the work surface so the top flap opens away from the body.
⦁ nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
A. The client's partner
Rationale: Legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney.
B. The client
Rationale: If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.
C. The client's daughter, who is the primary caregiver
Rationale: Although the primary caregiver cares for the client, legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney. Caring for a client does not give the client's daughter legal authority regarding health care decisions.
D. The client's son, who has a durable power of attorney
Rationale: A durable power of attorney for health care is a legal document that designates an individual authorized to make health care decisions for a client who is unable. The client's son should be familiar with the client's wishes.
135.A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)
A. The date of the incident
B. The name of the provider who prescribed the medication
C. The potential adverse effects of the medication
D. The time the client was to receive the medication
E. The client's vital signs
Rationale: The date of the incident is correct. When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date.
The name of the provider who prescribed the medication is incorrect. The nurse does not need to include the name of the provider who prescribed the medication as this information is part of the client's medical record.
The potential adverse effects of the medication is incorrect. The nurse should only include factual information about the incident and not potential effects.
The time the client was to receive the medication is correct. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication.
The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report.
⦁ nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager?
A. Ask other staff nurses about the level of care the specific staff nurse provides.
Rationale: This action is inappropriate because it does not directly address the issue and does not show respect for the specific staff nurse.
B. Address the concern with the specific staff nurse.
Rationale: The nurse manager should use the conflict management skill collaborating to resolve the conflict. The nurse manager should be assertive and ask the specific staff nurse about the problem.
C. Recommend the specific staff nurse be transferred to another unit.
Rationale: This action is inappropriate because it does not directly address the issue and does not show respect for the specific nurse.
D. Notify the human resources department about the request.
Rationale:
This action is inappropriate because it does not directly address the issue and does not show respect for the specific nurse.
137.A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
A. A client who has a punctured femoral artery
Rationale: A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged.
⦁ A client who has multiple fractures
Rationale: A client who has multiple fractures requires treatment within 2 hr. The nurse should identify this client as urgent or yellow-tagged.
⦁ A client who has a red rash over his abdomen
Rationale: A client who has a red rash over his abdomen can wait 2 hr or more to receive treatment. The nurse should identify this client as nonurgent or green-tagged.
⦁ A client who reports severe flank pain radiating to the groin
Rationale: A client who reports severe flank pain radiating to the groin requires treatment within 2 hr. the nurse should identify this client as urgent or yellow-tagged.
⦁ nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take?
A. Vigorously rub the skin following a decontamination shower.
Rationale: Sarin gas is a nerve agent that is spread through the air and can be inhaled or absorbed through the skin. Following decontamination with soap and water or bleach, the nurse should pat the skin dry to avoid rubbing more of the agent into the skin.
B. Initiate seizure precautions.
Rationale: Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen.
C. Provide respiratory support with a plastic oral airway.
Rationale: Symptoms of sarin gas exposure includes bronchoconstriction and laryngeal spasms requiring support of the airway. The nurse should avoid using plastic artificial airways because they can absorb the sarin gas resulting in continued exposure of the client to the agent.
D. Prepare to administer amyl nitrate.
Rationale: Symptoms of nerve gas exposure mimic those of a cholinergic crisis. Medications used in
treatment include atropine, pralidoxime, and diazepam. Amyl nitrate is used in the treatment of blood agent exposure, such as cyanide.
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