RN Concept Based Assessment Level 4 Online Practice A | Q & A (Complete Solutions)

RN Concept Based Assessment Level 4 Online Practice A | Q & A (Complete Solutions) | Q & A (Complete Solutions) A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which ...

RN Concept Based Assessment Level 4 Online Practice A | Q & A (Complete Solutions) | Q & A (Complete Solutions) A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which statement by the client indicates an understanding of the teaching? "I should inspect my skin daily for cuts and rashes" A nurse is caring for a client who has Parkinson's disease. Which of the following actions should the nurse take to promote the client's mobility? Instruct the client to perform range-of-motion exercises - The nurse should instruct the client to perform stretching and range-of-motion exercises to promote mobility. exercising and walking help to delay the progression of the disease. A nurse is caring for a client who has had a myocardial infarction and suspects cardiogenic shock. The nurse should monitor for which of the following manifestations? Pulmonary Congestion -Pulmonary congestion is a result of decreased cardiac output due to damage to the cardiac muscle A nurse is assessing a client who has a DNR order and has stopped breathing. The family asks the nurse to resuscitate the client. Which action should the nurse take? Respect the client's preferences. A nurse manager is teaching a group of nurses about OSHA. What information should the nurse include? Sets standards for hazardous exposures in the workplace. A nurse manager identifies that the number of client medication administration errors on the unit has increased. When creating a cause-and-effect chart, which of the following information should the nurse manger include? Possible reasons for the medication errors. -The nurse manager should identify and include possible reasons for the occurrence of medication errors when creating a cause and effect chart. This data assists in the prevention of future medication errors. A nurse manager notices that he has exceeded the amount of money allocated for labor costs for the quarter. Which action should the nurse manager take? involve staff nurses in budge planning. -this promotes awareness of the costs of staffing a unit and encourages cost-effective care. A nurse is providing teaching to a client who has a halo device applied to prevent further cervical spinal cord injury following a diving accident. What info should the nurse include? "Avoid leaning forward when attempting to stand." -the weight of the halo device can alter balance. leaning forward could cause the client to fall. A nurse is working on an interprofessional collaboration plan of care for a client who has a stage 3 pressure ulcer. Which action should the nurse recognize as the. role of the licensed practical nurse (LPN)? Administer pain medication A nurse manager is facilitating conflict resolution between two nurses who disagree about the need to make a referral to a social worker. Which conflict management strategies should the nurse manager use? Offer self to constructively facilitate communication. -The nurse manager will be the impartial third party in this communication A nurse is having a disagreement with a coworker about a client assignment. When following the chain of command, which of the following individuals should the nurse contact to discuss the conflict? The charge nurse - When following the chain of command, the nurse should communicate with his immediate supervisor about any questions and concerns he has, including a conflict with a coworkers. A triage nurse is prioritizing clients following a mass casualty disaster. Which of the following clients should the nurse treat first? A client who is exhibiting manifestations of shock. -a client exhibiting manifestations of shock requires immediate intervention for survival. A nurse is caring for a client who has a partial-thickness burn and a prescription for a silver sulfadiazine cream. Which intervention should the nurse take? Monitor the client's WBC. -A drop in the WBC count can be an indication of an allergic reaction to the silver sulfadiazine cream A nurse is preparing to administer nitroglycerin topical ointment to a client who had a myocardial infarction. Which action should the nurse plan to take? (move steps in order) 1) Cleanse the client's skin and allow it to dry 2) Apply a thin layer of medication ointment to the dosing paper. 3) Spread the medication over a 6.4 by 8.9 cm area of skin 4) Cover the medication site with plastic wrap 5) Remove the medication in 6 hr. A nurse manager is teaching a group of nurses about professional negligence. Which of the following situations should the nurse manager include as an example? Administering heparin to a client who is undergoing a lumbar puncture. A nurse who administers heparin to client who is undergoing a lumbar puncture is an example of negligence. Anticoagulant medication can cause bleeding in the lumbar area A nurse is teaching a client who has deep-vein thrombosis and is receiving heparin injections. The nurse should instruct the client to report which of the following manifestations as an adverse effect of this medication? An increase in nosebleeds -increase in nosebleeds or bruising can be indications of a hemorrhage, which is an adverse effect of heparin A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which should the nurse identify as a primary care setting? Outpatient counseling clinic -primary care setting clinics provide strategies for clients to prevent or delay mental health issues A nurse manager is informed that the family of a client is preparing to file a malpractice lawsuit. The nurse should identify which of the following situations as potential malpractice? Failure to identify an infiltrated IV -The nurse manager should identify that failure to provide reasonable care, such as identifying IV infiltration, can contribute to malpractice. The nurse should provide care that a reasonably prudent nurse would provide under the same circumstances. A community health nurse is planning a public health presentation aimed at minimizing health care disparities. Which of the following age groups should the nurse identify as the priority for increasing health literacy? Older Adults - Evidence-based practice indicates that the nurse should target older adults because this age group has the lowest level of health literacy compared to other groups. A charge nurse is planning care for a group of clients. Which task should the nurse delegate to the LPN? Obtain a blood glucose level from a client who has type 1 diabetes mellitus. -Obtaining a blood glucose level from a client who has type 1 diabetes mellitus is within the scope of practice of the LPN. A nurse is planning care for a child who has cystic fibrosis. Which intervention should the nurse include? Increase the child's daily fat intake to 40% of total calories -due to impaired intestinal absorption of fat A nurse manager is teaching a unit nurse about case management. What information should the nurse manager include in the teaching about the role of the nurse as a case manager? Advocates for services the client needs A nurse case manager's role is to advocate for services needed and available resources to meet the client's needs. A nurse is caring for a female client who has an indwelling urinary catheter. Which action should the nurse take to minimize the risk for catheter-related infection? Evaluate the client daily for the necessity of continued catheterization. -increased dwelling time increases the client's risk for infection. Catheter should be DC'd as early as possible A charge nurse is educating unit nurses about the ethical principle of nonmaleficence. Which example should the nurse include in the teaching? A nurse uses a mechanical lift to move a client from a bed to a chair. -The nurse is using the ethical principal of nonmaleficence by providing a mechanical lift to move the client from the bed to the chair, which prevents harming to the client. A nurse is teaching about managing care with the family of a client who has Parkinson's disease and takes dopamine. Which information should the nurse include in the teaching? Allow the client to perform ADLs -promotes and maintains independence for as long as possible A nurse is caring for a client who has cirrhosis. The client has an ammonia level of 120 mcg/dL, slurred speech, and is disoriented to person and place. The nurse should identify that these findings possibly indicate which of the following complications of cirrhosis? Hepatic encephalopathy -elevated ammonia level, slurred speech, and mental status changes are early manifestations of hepatic encephalopathy A nurse is caring for a client who has Addison's disease and is receiving an infusion of 0.9% sodium chloride. The client develops acute adrenal insufficiency. Which action should the nurse take? Check the client's blood glucose level -hypoglycemia is a manifestation of acute adrenal insufficiency. Glucose should be monitored hourly A nurse is caring for a client who has a pressure ulcer. Which action should the nurse take when cleaning the client's wound? Warm the cleansing solution to the client's body temperature - This action prevents the solution from lowering the wound temperature and promotes healing. A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication? Decreased ammonia level - The nurse should identify that a decrease in the client's ammonia level is a therapeutic effect pr lactulose. This medication decreased ammonia levels by producing a laxative effect. Another therapeutic effect of the medication is decreased confusion. A nurse is developing a plan of care for a client who has sustained burns to the lower half of his body and is to receive hydrotherapy. Which action should the nurse include in the plan? Use forceps and scissors to remove the loose, dead tissue from the client's wound - The nurse should use scissors and forceps to remove loose, dead tissue from the client's wound during hydrotherapy to promote healing. A nurse is performing an admission assessment on a client who has meningitis. Which finding should the nurse expect? Positive Kernig's Sign -this is expected due to meningeal irritation. When Kernig's sign is present, the client can't fully extend her leg when lying supine with her thigh flexed toward her abdomen A nurse in a substance use treatment facility is caring for a group of clients. Which action by the nurse demonstrates the ethical concept of fidelity? The nurse keeps a promise to take a walk outside with a client after group therapy -The nurse kept a promise made to a client. A nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which action should the nurse take? Contact a trained interpreter to translate the teaching for the client. The nurse's role is to contact a professional interpreter who is trained in medical terminology to promote the client's understanding of the teaching. A nurse is assessing an infant who has meningitis. Which manifestation should the nurse expect? Hypothermia -other manifestations can include vomiting, seizures, and nuchal rigidity A nurse who works on a med-surg unit is asked to float to the maternal newborn unit due to short staffing. Which professional organization protects the nurse if she refuses the assignment? American Nurses Association (ANA) A nurse is teaching a client who has a new prescription for carvedilol following a myocardial infarction. What information should the nurse include? "You should check your pulse before taking this medication" -The nurse should instruct a client who is taking carvedilol to obtain his heart rate prior to taking the medication. The client should withhold his medication and notify his provider if his heart rate is less than 60/min A nurse is assessing a newborn. Which of the following findings should the nurse identify as a manifestation of sepsis? Grunting -grunting, nasal flaring, retractions, apnea, tachycardia, hypotension, lethargy, pallor, petechiae, hypoglycemia, hypotonia, and/or decreased oxygen saturations are other symptoms of sepsis A nurse is reviewing the lab values of a client who is in hypovolemic shock. Which of the following findings should the nurse expect? pH level 7.25 - The nurse should expect the client's laboratory values to reflect metabolic acidosis. The client's pH level is decreased due to insufficient tissue perfusion. A pH level of 7.25 is below the expected reference range. A nurse is teaching an educational session about reducing health care-associated infections. Which instruction should the nurse include? Bathe the clients daily with chlorhexidine wipes A nurse is caring for a client who is post-op following a craniotomy to remove a brain tumor. The nurse should notify the provider about which of the following findings? Fixed an nonreactive pupils to light -This is an indication of a neurological deficit due to a herniation of the brain A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which instruction should the nurse include in the teaching? "Avoid drinking grapefruit juice when taking this medication." -Grapefruit juice can decrease the metabolism of cyclosporine, which can cause an increase in serum levels and increase the risk for toxicity A nurse is providing discharge teaching for a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? "Lie down when you take this medication" -nitroglycerin is a vasodilator that can cause hypotension. Other adverse effects include headache, flushing, and tachycardia A chief nurse officer (CNO) is comparing the quality of health care at her facility to the best-performing facilities nationwide to determine if quality improvement is required. Which of the following processes should the CNO plan to use as a comparison tool? Benchmarking -Benchmarking measures products, services, and practice against top-performing organizations. Facilities use this as a tool for developing desired standards of organizational performance A nurse is caring for a client who has sepsis and has developed Disseminated Intravascular Coagulation (DIC). Which of the following actions should the nurse take? Administer anticoagulants to the client - The nurse should administer anticoagulants to limit the clotting. A nurse is caring for clients on a med-surg unit. Which of the following actions by the nurse demonstrates the professional characteristics of human dignity? The nurse treats each of his assigned clients with equal respect A nurse is caring for a client who is in the active phase of labor and has an amniotic fluid embolus. Which action should the nurse take? Give O2 via nonrebreather mask at 10L / min -additionally, the nurse should prepare for intubation and mechanical ventilation A nurse is caring for a client who is 6hr post-op following a TKA. Which action should the nurse take to prevent a pulmonary embolism? Apply compression stockings to both o the client's legs A nurse is teaching a group of nurses about the role of a case manager. What information should the nurse include in the teaching? Identifies cost-effective equipment. - The nurse should inform the group that the case manager identifies treatments, care settings, and equipment to promote cost-effective positive outcomes. A nurse is reviewing the lab values of a client who has Addison's disease. Which finding should the nurse expect? Potassium 6.2 mEq/L -A client who has Addison's disease will have a potassium level that rapidly increases due to lack of cortisol concentration levels, which leads to a fluid and electrolyte imbalance. A potassium level of 6.2 mEq/L is above the expected reference range and is an expected finding for a client who has Addison's disease. A nurse is preparing to conduct research regarding catheter-related infections for a performance improvement initiative. Which of the following activities should the nurse identify as components of the research process? (SATA) Formulate the research problem (This action allows the nurse to define the purpose of the study and determine the type of research design she will use.) Conduct a pilot study (The nurse should conduct a pilot study, which can assist the nurse to identify the strengths and limitations of a planned larger-scale study. it can also assist with the assessment of the design and methodology of the research.) Communicate the conclusions of the study (The nurse should communicate the conclusions of the pilot study and the research conducted. Once the outcomes are disseminated, the new evidence-based practice can be incorporated into the daily practice of the facility.) A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which action should the nurse plan to take? Transfuse the platelets through a small filter - The nurse should transfuse the platelets through a small filter to remove white blood cells. NOTE: Platelets are administrated within 15 to 30 minutes and administered immediately to prevent platelet clumping. Platelets do not need to match as it is collected from multiple donors. Following a mass casualty disaster, a nurse is assigning a triage tag to a responsive client who has a major burn injury covering 15% of his body surface area. Which triage category should the nurse assign to the client? Red -This is a significant injury that requires immediate treatment A nurse is caring for a client who has sepsis. Which manifestation should indicate to the nurse that this client might be progressing to septic shock? Hypothermia - The nurse should recognize that a client who is progressing to septic shock can experience hypothermia as a result of the body's inability to compensate for the infection. Other signs/symptoms are: Tachycardia, Hypotension, decreased urine production. A nurse is caring for a group of postpartum clients. Which task should the nurse delegate to an assistive personnel? Measure the urine output of a client who is receiving magnesium sulfate. Measuring the urine output of a client who is receiving magnesium sulfate does not require use of the nursing process and is within the range of function of an assistive personnel. A nurse is reviewing the ECG strip of a client who is experiencing angina. Which characteristic should the nurse expect to find? T-wave inversion -The nurse should identify that an inverted T-wave indicates ischemia of the heart as a result of angina A nurse is providing teaching to a client following a kidney transplant from a cadaver donor. Which of the following statements by the client indicates an understanding of the teaching? "I will need to continue hemodialysis until my new kidney is functioning well" A nurse is preparing to provide wound care on a client who has a stage 1 pressure ulcer. Which of the following characteristics should the nurse expect the ulcerative skin area to have? Non-blanchable and reddened The nurse should expect a nonblanchable reddened are on the skin on a client for a stage I pressure ulcer. A nurse manager is teaching a newly licensed nurse about the Emergency Medical Treatment and Active Labor Act (EMTALA). Which of the following information should the nurse include? EMTALA requires that all clients are stable prior to discharge or transfer -EMTALA requires that clients are stable before they can be discharged or transferred. This act also prohibits refusing to care for clients who are indigent or uninsured. A nurse is providing discharge teaching to a client who has hepatitis. Which of the following information should the nurse include? "Avoid sexual intercourse until the antibody test is negative" -The nurse should inform the client to avoid sexual intercourse until the antibody testing results are negative A nurse is developing a plan of care for a client who has a traumatic brain injury after a fall. Which of the following medications should the nurse expect to administer to the client to reduce ICP? Mannitol -Mannitol is an osmotic diuretic that decreases cerebral edema A nurse in risk management is evaluating a sentinel event. Which of the following actions should the nurse take? Develop a plan to reduce the risk for client injury -the nurse should develop a plan to reduce the risk for negligence and prevent another sentinel event from occurring A nurse is caring for a client who has a new diagnosis of esophageal cancer. The client's family tells the nurse that they do not want the client to know the diagnosis. Which of the following actions should the nurse take to uphold client autonomy? Tell the family the client has the right to know about her health -The nurse is demonstrating the ethical principle of autonomy by respecting the client's right to make decisions about her health