Which client should the telemetry nurse assess first after receiving the a.m. shift report?

1. A nurse receives a change-of-shift report at 0700 for an assigned caseload of clients. Number the following clients in the order in which they should be seen.

1
The first action the nurse should take is to attend to the client who is receiving blood. It has been 3 hr since the transfusion was initiated, and it should be completed within 4 hr. The client is also at risk for a transfusion reaction; therefore, this is the first action the nurse should take.

1. 3 Next the nurse should administer PRN pain medication to the client who was last medicated at 0430.
   
2. 4 Then the nurse should verify that the informed consent is completed in sufficient time to take any actions needed prior to the scheduled colonoscopy.
   

2 The next action the nurse should take is to administer the insulin, which is scheduled to be administered before 0800.
5 Finally, the nurse should reinforce teaching for the client who is to be discharged and has a prescription for dressing changes.

2. An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first?

C. CORRECT: Using the nursing process, the first action the nurse should take is to assess the client. Therefore, the first action the nurse should take is to inspect the client for injury.

3. A nurse is preparing to initiate IV therapy for a client who has a prescription for morphine 10 mg IV bolus. Using time management principles, which of the following actions should the nurse take first?

CORRECT: The first action the nurse should take is to mentally envision the task to ensure that she has all of the needed supplies to avoid wasting time by having to make another trip to obtain supplies.

4. An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN?

1. A. CORRECT: It is within the scope of practice of the LPN to monitor a client who is 2 hr post procedure for a cardiac catheterization.
   

5. An LPN ending her shift reports to the RN that a newly hired assistive personnel has not calculated the
intake and output for several clients. Which of the following actions should the RN take?

1. C. CORRECT: The nurse should find out what the AP knows about performing the task and provide education for the AP if indicated.
   

6. A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following should the manger include in the plan? (Select all that apply.)

1. A. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include evaluation of skill proficiency and provide additional instruction as indicated.
   
2. B. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include assignment of a preceptor to ease the transition of the newly licensed nurse.
   
3. D. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include computerized charting, which is an essential skill for the newly licensed nurse. E. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include socialization to unit as a way to ease the transition of the newly licensed nurse.
   

F. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include information about facility policies and procedures, which is an essential information for the newly licensed nurse.

7. A nurse manager is providing information about the audit process to members of the nursing team. Which of the following statements should the nurse manager include? (Select all that apply.)

A.CORRECT: A structure audit evaluates the setting in which care is provided and includes resources such as equipment and staffing levels.

CORRECT: An outcome audit evaluates the effectiveness of nursing care. It should include observable data such as infection rates among clients.CORRECT: A root cause analysis is indicated when a sentinel event occurs. A sentinel event is a serious problem such as injury to or death of a client. Immediate investigation of the problem is indicated. The health care team may use root cause analysis to study the problem and take measures to prevent reoccurrence.

1. CORRECT: The benchmark is set at the beginning of the process and then it is compared to the data after collection is completed.
   

8. A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following will provide the most relevant information regarding the efficacy of the procedure?

1. CORRECT: The incidence of complications related to the procedure is an outcome measure related to the efficacy of the procedure.
   

9. A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating?

A.
NCLEX® Connection: Management of Care, Performance Improvement (Quality Improvement)
CORRECT: The goal in resolving conflict is a win-win situation. The unit manager is using an ineffective strategy, avoidance, to deal with this conflict. She is aware of the conflict but is not attempting to resolve it.

10. A nurse has received a performance appraisal from the unit manager. Which of the following actions by the unit manager requires intervention?

1. CORRECT: The unit manager should only use data that has been observed and formally documented.
   

11. A nurse manager is discussing emotional intelligence with the charge nurses on her team. What statements should the manager include in this discussion? Use the Active Learning Template: Basic Concept to complete this item to include the following sections:

Underlying Principles

• ● Insight into the emotions of members of the team.
  
• ● Understands the perspective of others.
  
• ● Encourages constructive criticism and is open to new ideas.
  
• ● Able to maintain focus while multitasking.
  
• ● Manages emotions and channels them in a positive direction, which in turn helps the team accomplish its goals.
  
• ● Committed to the delivery of high-quality client care.
  
• ● Refrains from judgment in controversial or emotionally charged situations until facts are gathered.
  

1. A nurse is preparing to transfer an older adult client who is 72 hr postoperative from a surgical procedure to a long-term care facility. Which of the following should the nurse include in the transfer report? (Select all that apply).

1. A. INCORRECT: The nurse should include only information that is pertinent in the transfer report. B. CORRECT: The nurse should include information that is pertinent and that the next nurse will need when providing care. C. INCORRECT: The nurse should include only information that is pertinent in the transfer report. The nurse should include the client’s most recent vital signs. D. CORRECT: The nurse should include information that is pertinent and that the next nurse will need when providing care. E. CORRECT: The nurse should include information that is pertinent and that the next nurse will need when providing care.
   

2. A nurse is participating in an interprofessional conference for a client who has a recent C6 spinal cord injury. The client worked as a construction worker prior to his injury. Which of the following members of the interprofessional team should also participate in planning care for this client? (Select all that apply.)

C. CORRECT: The nurse should advocate for the client by ensuring that the client understands the purpose of advance directives. Seeking the assistance of a client representative to provide information to the client is an appropriate action.

3. A nurse manager is working with a committee of nurses whose task is to update the policies for new employee orientation. The nurse manager directs the team to collect as much data as possible and recommend several options. Which of the following decision-making styles is being demonstrated by the nurse manager?

1. D. CORRECT: When the integrative decision-making style is used, the team uses a large amount of data and generates several options.
   

4. A nurse who has just assumed the role of unit manger is examining her skills in interprofessional
collaboration. Which of the following actions support interprofessional collaboration? (Select all that apply.)

1. A. INCORRECT:Thenurseshoulduseassertiveskillswhencommunicatingwiththeinterprofessionalteam. B. CORRECT: The nurse should recognize that each member of the team has specific skills to assist the client with rehabilitation. C. INCORRECT: A nurse can serve as the facilitator, but this role can be assumed by any member of the team. D. CORRECT: Collaboration should occur among the client, family, and interprofessional team. E. CORRECT:Thenurseshouldsupportsuggestionsforreferralstolinkclientstoappropriateresources.
   

5. A nurse on a telemetry unit is caring for a client who was admitted 2 hr ago and has chest pain. The client becomes angry and tells the nurse that there is nothing wrong with him and that he is going home immediately. The nurse should base her actions on which of the following? (Select all that apply.)

1. A. INCORRECT: The nurse does not need to notify the risk manager immediately. However, it is imperative that the nurse notify the provider of the client’s intention to leave so the provider can intervene and decrease the risk of a negative client outcome. B. CORRECT: When documenting a client’s discharge, the nurse should document the type of discharge, including an AMA discharge. C. CORRECT: If the client leaves before the provider arrives, the nurse is legally responsible to warn the client of the risks involved in leaving the hospital. D. CORRECT: Clients who leave the hospital prior to discharge are asked to sign a form to provide legal protection for the hospital. E. CORRECT: A nurse who tries to prevent a client from leaving the hospital by any action, such as threatening him, or refusing to give him his clothes, may be charged with assault, battery, and false imprisonment.
   

6. A nurse is explaining her role as case manager to her preceptor. What should the case manager include in her discussion? Use the ATI Active Learning Template: Basic Concept to complete this item. Identify three roles of a case manager.

● Roles of a Case Manager

• ◯
• 
  
• Coordinating care of clients who have complex health care needs
  
• ◯
• 
  
• Facilitating continuity of care
  
• ◯
• 
  
• Improving efficiency of care
  
• ◯
• 
  
• Enhancing quality of care provided
  
• ◯
• 
  
• Limiting cost and lengthy stays
  
• ◯
• 
  
• Advocating for the client and family
  

1. A nurse manger is observing the actions of a nurse she is supervising. Which of the following actions by the nurse requires the nurse manager to intervene? (Select all that apply.)

A.

1. CORRECT: Paper copies of confidential information create a risk for breach of confidentiality.
   
2. CORRECT: Information about a client’s condition is disseminated on a need-to-know basis. It is inappropriate to share this information with the hospital clergy.
   
3. INCORRECT: The nurse can share information with an individual who has been provided the information code.
   
4. CORRECT: Sharing information in the hallway where it can be overheard by others can result in a breach of confidentiality.
   

2. A nurse is caring for a client who is being prepared for surgery. The client hands the nurse information about advance directives and states, “Here, I don’t need this. I am too young to worry about life-sustaining measures and what I want done for me.” Which of the following actions should the nurse take?

3. A nurse is serving as a preceptor to a newly licensed nurse and is explaining the role of the nurse as advocate. Which of the following situations illustrates the advocacy role? (Select all that apply.)

A.
CORRECT: Ensuring that the client has given informed consent illustrates nurse advocacy.

1. INCORRECT: Discussing treatment options is not within the scope of practice of the nurse.
   
2. CORRECT: Ensuring that the client’s care is consistent with his do-not-resuscitate status illustrates nurse advocacy.
   
3. CORRECT: Ensuring that all clients receive proper care illustrates nurse advocacy.
   
4. INCORRECT: Assisting a client to make decisions about his care based on nurse recommendations is inappropriate. The nurse should support the client in making his own decisions.
   

4. A nurse manager is providing information to the nurses on the unit about ensuring client rights. Which
of the following outlines the rights of individuals in health care settings?

D. CORRECT: The Patient Care Partnership is a document that addresses clients’ rights when receiving care.

5. A nurse is reviewing a client’s health care record and discovers that the client’s do-not-resuscitate (DNR) order has expired. The client’s condition is not stable. Which of the following actions should the nurse take?

1. CORRECT: The nurse should immediately call the provider to determine whether the order should be reinstated. This is the action to take to be sure that the client’s wishes are carried out.
   

6. A toddler is being treated in the emergency department following a head contusion from a fall. History reveals the toddler lives at home with only her mother. The provider’s discharge instructions include waking the child up every hour during the night to assess for indications of a possible head injury. In which of the following situations should the nurse intervene and attempt to prevent discharge?

C. CORRECT: It would be unsafe to discharge a toddler who requires hourly monitoring with a mother who may be chemically impaired.

7. A newly licensed nurse is preparing to insert an IV catheter in a client. Which of the following sources should the nurse use to review the procedure and the standard at which it should be performed?

1. CORRECT: The institutional policy and procedure manual will provide instructions on how to perform the procedure that is consistent with established standards. Therefore, this is the resource the nurse should use.
   

8. A nurse witnesses an assistive personnel (AP) under her supervision reprimanding a client for not using the urinal properly. The AP threatens to put a diaper on the client if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?

NCLEX® Connection: Management of Care, Information Technology
CORRECT: Assault is conduct that makes a person fear he or she will be harmed.

9. A nurse is preparing to serve on a committee that will review the policy on disruptive behavior. Use the ATI Active Learning Template: Basic Concept to complete this item to include the following:

A. Related Content
● Lateral violence is also known as horizontal abuse or horizontal hostility.
B. Nursing Interventions

• ● Create an environment of mutual respect among staff.
  
• ● Model appropriate behavior.
  
• ● Increase staff awareness about disruptive behavior.
  
• ● Make staff aware that offensive online remarks about employers and coworkers are a form of bullying and is prohibited even if the nurse is off-duty and it is posted off-site of the facility.
  
• ● Avoid making excuses for disruptive behavior.
  
• ● Support zero tolerance for disruptive behavior.
  
• ● Establish mechanisms for open communication between staff nurses and nurse managers.
  
• ● Adopt policies that limit the risk of retaliation when disruptive behavior is reported.
  

1. A home health nurse is assessing the safety of a client’s home. Which of the following factors may increase the client’s risk for falls? (Select all that apply.)

CORRECT: A client who has had a previous fall is at risk for another fall.

1. CORRECT: Reduced vision makes it difficult for the client to avoid mishaps with equipment and furniture.
   
2. CORRECT: A client who has impaired memory may not ask for help with ambulation or ADLs.
   
3. INCORRECT: This medication does not place the client at risk for falls.
   
4. CORRECT: House slippers may not provide adequate traction and support for safe ambulation.
   
5. CORRECT: Kyphosis, which is a type of curvature of the spine, alters a client posture and center of balance and may place the client at risk for falls.
   

2. A client is brought back to the unit after a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocate the new hip joint, and he repeatedly attempts to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

CORRECT: If a client is in imminent danger of harming himself, the nurse can apply restraints immediately.

1. CORRECT: The nurses must obtain an order from the provider as soon as possible, typically within 1 hr.
   
2. CORRECT: A family member must sign a consent for the restraint.
   
3. INCORRECT: A quick-release knot must be used to secure the restraint to the bed frame.
   
4. INCORRECT: The distance between the restraint and the client should be two finger widths.
   

3. A nurse is observing a newly licensed nurse and an assistive personnel (AP) pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates a need for further education?

C. CORRECT: This action by the nurse requires intervention. The nurse’s feet should be pointing at the head of the bed instead of the center of the bed.

4. An assistive personnel (AP) reports that a client’s finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client’s morning finger-stick blood glucose was 285 mg/dL. The client is asymptomatic for hypoglycemia, and his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?

1. A. CORRECT: Because the blood glucose was 285 mg/dL a few hours ago, it is unlikely that the blood glucose is 58 mg/dL at this time. Therefore, the nurse should recalibrate the glucometer and recheck the client’s blood glucose.
   

5. A staff nurse is reviewing the hospital’s fire safety policies and procedures with newly hired assistive personnel. The nurse is describing what to do when there is a fire in a client’s trash can. Which of the following statements should the nurse include? (Select all that apply.)

1. C. CORRECT: Ambulatory clients can walk by themselves to a safe place. D. CORRECT: The fire extinguisher PASS sequence is pull the pin, aim at the base of the fire, squeeze the lever, and sweep the fire extinguisher from side to side. E. CORRECT: The employee should close all doors to contain the fire.
   

6. A nurse manager is preparing to discuss electrical safety with the nurses on her unit. List the information that should be included in the discussion for each of the following aspects of safety. Use the ATI Active Learning Template: Basic Concept to complete this item. In the section Underlying Principles, identify the frequency in which the nurse should check equipment, and list four measures to prevent electrical shock.

● Underlying Principles

• ◯
• 
  
• The nurse should check all equipment at the beginning and end of each shift.
  
• ◯
• 
  
• Measures to Prevent Electrical Shock
  
• „ Ensure that all electrical equipment has a three-way plug and grounded outlet.
  
• „ Ensure that outlet covers are used in areas such as pediatric and mental health units.
  
• „ When unplugging equipment, grasp the plug, not the cord.
  
• „ Disconnect all equipment prior to cleaning.
  
• „ Ensure that outlets are not overcrowded.
  
• „ Use extension cords only when absolute necessary; if used in an open area, tape the cords to the floor.
  

1. A nurse discovers that a client was administered an antihypertensive medication in error. Number the following actions in the appropriate sequence that the nurse should follow.

Correct order B. Using the nursing process, the first action the nurse should take is to monitor the client for
hypotension by monitoring the client’s vital signs.
E. Next, the nurse should instruct the client to remain in bed to prevent a fall due to the risk of hypotension.
A. Then the nurse should notify the provider, who may prescribe a medication to treat hypotension. D. Next, the nurses should complete an incident report that is thorough and accurate. C. The last step the nurse should take is to report the incident to the risk manager.

2. A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? (Select all that apply.)

CORRECT: The nurse should document a factual description of the event in the client’s health care record.

CORRECT:Incidentreportsareconfidentialandnotsharedwiththeclient.

CORRECT: In addition to providing an accurate description of the event, the nurse also shoulddocument the actions taken following the event.

CORRECT:Riskmanagersinvestigateallincidentsaspartoftheagency’squalityassuranceprogram.

3. An individual approaches the door of the maternal newborn unit, states that he is the uncle of a newborn, and asks to be admitted to the unit. Which of the following actions should the nurse take?

1. CORRECT: Access codes are provided to clients admitted to the maternal newborn units to protect newborns from abduction and to promote client confidentiality.
   

4. A community experiences an outbreak of meningitis, and hospital beds are urgently needed. Which of the following clients should the nurse recommend for discharge?

1. B. CORRECT: This client is stable, and he can be safely discharged.
   

5. A nurse on a sixth-floor medical surgical unit is advised that a severe weather alert code has been
activated. Which of the following actions should the nurse take? (Select all that apply.)

1. A. CORRECT: The nurse should close the window shades and drapes to protect clients from shattering glass. B. CORRECT: The nurse should move the beds of nonambulatory clients away from windows to protect clients from shattering glass. C. CORRECT: The nurse should relocate ambulatory clients into the hallway to protect the clients from shattering glass. D. INCORRECT: Although it may be safer on a lower floor, it is unsafe to use the elevator. E. CORRECT: The nurse should use the radio to monitor the activity of the storm.
   

6. A nurse serving on a disaster preparedness committee is reviewing information about smallpox. Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following:

A. Objective and Subjective Findings

• ● High fever
  
• ● Fatigue
  
• ● Severe headache
  
• ● Rash B. Treatment
  
• ● Prevent dehydration.
  
• ● Provide skin care.
  
• ● Administer medications for pain and fever.
  

● Chills ● Vomiting ● Delirium

A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's highest priority?

Assign client care to staff

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

"Check the urinary output at 1100 for John Doe and report it to me immediately."

A client with altered mental status and a right lower leg deep vein thrombosis has a prescription for application of an aquathermia pad to the right lower leg. Which of the following is the highest priority by the nurse to ensure client safety?

Check the clients leg 10 minutes after applying the aquathermia pad.

A nurse on a medical -surgical unit has arrived late to work multiple times over the past several weeks. The nurse manager is planning to use progressive discipline to addresee the problem. (Order the steps of this process)

1) Issue an informal verbal reprimand
2) Give the nurse a formal written reprimand
3) Suspend the nurse without pay
4)Terminate the nurse's employment

A women brings in her 15 year old grandson to the emergency department reporting that he has severe abdominal pain, and he is scheduled for an immediate appendectomy. The nurse confirms that the client's p[parents are unavailable. Which of the following actions is appropriate?

Have the grandma sign the consent form

A nurse is planning the discharge for a new mother and her newborn, who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the client?

A nurse manager notices an increase in the number of clients acquiring health care-associated infections on the unit. Using the process of auditing quality control, which of the following actions should the nurse take first?

Use benchmarks to establish practice standards

A nurse is caring for 4 clients. Which of the following assessment findings is the highest priority?

An older adult client with a femur fracture reports felling short of breath.

A nurse is caring for four clients. Which of the following clients requires the most immediate intervention?

A client with a history of esophageal varices who has diaphoresis and pallor

A newly hired assistive personnel (Ap) is asked by a nurse to remove an indwelling catheter from a client. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Review the AP's skill competency checklist.

Two nurses on a unit each contend that the other is not doing their fair share of work. The conflict is affecting the functioning of the unit. The charge nurse should recognize that which of the following is an appropriate approach to this conflict?

Explore alternative solutions will allow the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution.

A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take?

Report this issue to the nurse manager.

AN RN IS precepting a newly licensed nurse in an acute care facility. When instructing the nurse about advance directives, which of the following statements should the RN make?

" There must be documentation in the medical record about whether a client has advance directives"

A nurse is observing an assistive personnel who is caring for a group of clients. Which of the following actions by the AP demonstrates effective use of time management skills in providing client care?

Grouping activities for several clients in the same location

A case manager is planning an interdisciplinary conference for a client who is 3 days postoperative following an open reduction with internal fixation of the right hip. Which of the following is the highest priority for discussion at the conference?

The client refuses to attend physical therapy sessions

A charge nurse is managing conflict with a staff nurse who does not agree with the client care assignment. Which of the following statements is an example of using the conflict resolution strategy known as smoothing?

"you always complete your work on time and do a great job. I believe you can handle the assignment well"

A nurse is presenting information on health care law to a group of newly hired nurses. Which of the following information should the nurse include?

The patient self determination act (PSDA) requires a nurse to give clients information about end-of-life options

A client who has cancer vomits blood on the bed linens and the floor. The nurse should ensure that which of the following is done to safely clean the client's environment?

The floor is mopped with a bleach solution.

A nurse is caring for an older adult client who has renal failure. The client tells the nurse that he has decided to stop hemodialysis treatment. Which of the following actions by the nurse is appropriate in regard to serving as the client's advocate?

Supporting the client's decision regarding treatment

A nurse is precepting a newly licensed nurse who is caring for a client who has suspected tuberculosis. The nurse should iinstruct the newly licensed nurse that standard infection control procedures in this situation include?

Wearing particulate respirator masks

A nurse is working on a medical surgical unit in an acute care facility. Which of the following events requires the nurse to file an incident report?

A nurse administers an antibiotic 45 min late because the medication was not available.

A nurse is caring for an older adult client who is hospitilized and has expressive dysphagia. The clients clients family reports that the nurse failed to obtain written consent before inserting an indwelling urinary catheter. Which of the following is an appropriate response by the nurse?

This is a procedure that does not require written informed consent

The charge nurse on a medical-surgical unit is making shift assignments for the next shift. A licensed practical nurse (LPN) and assistive personnel (AP) are members of the team. Which of the following client care assignments should the nurse assign to the LPN?

Reinforcing teaching to a client

A nurse on a medical-surgical unit is caring for a patient who is terminally ill. Which of the following actions demonstrates that the nurse is practicing in an ethical manner when caring for the client?

Collaborate with the client to establish realistic goals for her end of life care.

A nurse on a med/surg floor is assigned 4 clients. which of the following requires the most immediate intervention?

A client who reports substernal chest discomfort with a rating of 4 out of 10

A nurse administrator is developing a list of recommendations for her supervisor on how to use evidence based practice (EBP) to improve client outcomes. Which of the following should the nurse recommend as a qualitative research method?

A nurse is admitting a client to the cardiac intensive care unit. At what time during the hospital stay should the nurse assess the client's discharge planning needs?

At the time of the admission interview

A nurse is caring for a client who is terminally ill and is receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. The nurse should expect which of the following actions from the committee?

Assisting in weighing the options involved in the decision

There has been a massive community disaster and stable clients must be discharged from the hospital to prepare for the influx of new causalities. Which of the following clients is safe to discharge?

A client with multiple sclerosis who reports ataxia

A nurse manager is planning an educational program about the role of the nurse as a client advocate. Which of the following should the nurse include in the presentation?

The distribution of confidentiality disclosure information to clients

A nurse is caring for a client who has an informed consent form for an upcoming procedure in her health record. Which of the following is appropriate to validate that the client understands the procedure?

Ask the client to verbalize the purpose, risks, and benefits of the procedure

A nurse in the emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of large number of casualties. Which of the following clients should the nurse recommend for immediate evaluation by a provider?

A client who has a crushing chest would

A nurse is admitting an older adult client who has dementia to a med/surg unit. Which of the following may be an indicator of neglect?

The medications brought to the hospital for the client are expired.

A nurse manager is conducting an annual performance review for a staff nurse. Which of the following strategies is appropriate for the nurse manager to include in the review process? (Select all that apply)

- Include peer evaluations completed by an assistive personnel (Ap)

-Have a nurse complete a self appraisal prior to the review

- Conduct a performance checklist

When participating in the informed consent process prior to surgery, a nurse must?

Review previously provided information about the procedure

A charge nurse on a med/surg unit is planning care for a client who has dementia and is being admitted for surgery. Which of the following would promote safety when caring for this client?

Placing the client in a room near the nurses station

A home health nurse is planning her daily visits and recieves laboratory results for four clients. The nurse should first see the client with which of the following laboratory values?

A nurse working in the emergency department is witnessing informed consent from clients. Which of the following clients has the right to provide informed consent for treatment?

A client who has a blood alcohol level of 0.05

An occupational health nurse is triaging clients at the site of an industrial explosion. A class III, or green tag, should be assigned to the client with which one of the following manifestations?

A nurse manager is reviewing recent actions by staff to determine adherence with HIPPA guidelines. Which of the following actions by a nurse should the manager identify as adhering to HIPPA guidelines?

A nurse shares a client's test results with an AP on the same nursing team.

A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality?

Tell the clients partner that the results of his wife's laboratory tests cannot be disclosed without her permission

A nurse is caring for a client who asks for information about advanced directives. Which of the following is an appropriate response by the nurse?

"Your advance directives will take effect when you are unable to make health care decisions"

A nurse manager is reviewing the stages of conflict resolution with the nursing staff. The nurse manager should instruct the staff to expect the stages of the conflict to occur in what order?

1)Latent phase
2)Perceived conflict
3)Felt conflict
4)Manifest Conflict
5)Conflict aftermath

A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following patients should be assigned to the medical nurse?

A client who had a right above the knee amputation 24 hrs ago

An older adult client is being discharged with a post operative infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge?

Ensure that home infusion therapy has been arranged

A home health nurse is performing a home safety assessment who has a toddler. Which of the following findings is a potential environmental hazard the nurse should discuss with the parents?

The toilet seat lid is in the raised position.

A nurse manager is presenting an inservice about preventing readmission of clients due to complications after joint replacement surgery. Which of the following leadership tasks is the nurse performing?

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following should the nurse include?

Raise the footplates of the wheelchair before transferring the client

A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to a licensed practical nurse (LPN)?

A client who has Crohn's disease and requires an enteral feeding

A client reports to the emergency department with weakness, vomiting, and diarrhea for the past 3 days. Which of the following is the highest priority?

A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict?

"I'm not sure wether I want to apply for the unit manager's position or start a family this year"

A nurse is receiving change of shift report at the start of the shift. Which of the following clients should the nurse assess first?

A client who had abdominal surgery 6 hr ago and has a heart rate of 120/min for the last 2 hr

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, the first action the nurse manager should take is to?

Perform a chart review to gather data about the clients who developed infections

A nurse is caring for a group of clients on a unit. Which of the following assessments findings should the nurse recognize as the priority to report to the charge nurse?

A client who is 2 days postoperative and has a urine output of 20 ml/hr

A nurse in the emergency department is performing triage for a group of clients following a motor vehicle crash. Which of the following clients should the nurse request the provider assesses first?

A client who has arm contusions and manifests asymmetrical thoracic movement

A facility has identified an increase in health care associated urinary tract infections (UTIs) on the medical-surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process?

Establish best practice guidelines for reducing the incidence of UTIs

A charge nurse is evaluating a newly licensed nurse at the end of orientation. Which of the following indicates the nurse is using effective time management skills?

Makes a list of non-essential tasks to perform later

A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?  

LPNs provide care to class III (green tag) clients

A charge nurse is performing chart reviews on infection control precautions implemented by nursing personnel during the admission of clients to the unit. Which of the following is an appropriate infection control precaution?

Droplet precautions for a client who has meningcoccal pneumonia

A staff nurse at a long term care facility is evaluating an assistive personnel (AP) caring for a group of clients who require restraints. Which of the following is an appropriate action by the AP?

Placing the restraint tie on a moveable part of the bed frame

A nurse manager is planning a teaching session on use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following in the teaching about critical pathways?

Critical pathways prevent unnecessary expense

A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which is the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence?

Set a goal for improvement in adherence

A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. Which of the following should the nurse manager include in the teaching?

Verify that a provider prescription is in the medical record for clients who have restraints.

A nurse is caring for a school aged client who is seeking treatment for a laceration to the right forearm that occurred during soccer practice. The client was transported to the emergency department by a friend's parent and the soccer coach. The nurse should ensure that informed consent is given by

A nurse is caring for a client who has metastic cancer and decides not to continue treatment. Which of the following is an appropriate response by the nurse?

"Tell me what this is like for you"

A nurse is assessing a client who is postoperative and has a PCA. The client exhibits restlessness, an elevated pulse, and decreased blood pressure. Which of the following actions should the nurse take?

Place the client in a modified trendelenburg position

A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing about the failure of the AP to restock supplies. The AP leaves the room. Which of the following is an appropriate statement at this time by the nurse manager to the newly licensed nurse?

"I would like for you to approach the AP to resolve this problem"

A charge nurse is supervising a team of licensed practical nurses (LPNs) and assistive personnel (AP). The charge nurse should intervene in which of the following situations?

An LPN develops the nursing plan of care for a client who has pneumonia.

A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the new nurse indicates an understanding of these instructions?

"After I finish with the printout of my assignment, I'll put it in the shredder receptacle."

A nurse is working in the emergency department when there is an explosion in a local chemical plant. Multiple victims are expected at the facility. Which of the following should be the nurse's priority intervention upon client arrival?

Isolate the clients and irrigate with water

A nurse manager is making daily rounds on the unit and observes the following situations. which of the following indicates a legal issue?

A client has phlebitis at the site of an IV that has been in place for 4 days.

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, the first action the nurse manager should take is to?

Perform a chart review to gather data about the clients who developed infections

A nurse on a medical unit is determining the accuracy of web sites currently included in teaching materials for clients newly diagnosed with diabetes mellitus. The nurse should recommend that which of the following web sites be removed from the list?

A web site detailing new diabetic medications that is affiliated with a pharmaceutical company

A nurse should recognize that which of the following actions makes the nurse liable for professional negligence?

Failing to perform all the actions recorded by the nurse in a client's record

a charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects intrapersonal conflict?

"I'm not sure wether I want to apply for the unit manager's position or start a family this year"

A client is being transferred from the cardiac catheter laboratory to the cardiac care unit. Which of the following methods of communication by the nurse at the laboratory is most appropriate to ensure continuity of care?

Telephone report to the accepting nurse

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel?

"Check the urinary output at 1100 for john doe and report it to me immediately"

A nurse is consulting with a support group to provide health education for clients newly diagnosed with heart failure. Identify the order of the actions the nurse should take. 

1) Determine knowledge needed by the group

2) Develop learning objectives for the educational program

3) Encourage participation of the client's families

4)Determine client learning outcomes

A nurse asks an assistive personnel (AP) to obtain a fingerstick blood glucose and report the results immediately. Thirty minutes later, the nurse finds the AP in the nurse's lounge. The AP states, " The glucose was 345 mg/dl. I looked for you, but couldn't find you". Which of the following actions should the nurse take first?

Reinforce to the AP that the results should be reported right away

While assessing a client brought to the emergency department with injuries sustained in a motor vehicle crash, the nurse finds a limitation in the clients ability to move the toes on her left foot. X-rays indicate an L1-L2 fracture. Which of the following is the highest priority intervention?

Alert all staff to turn the client by log rolling

An RN is assigning tasks to team members. Which of the following tasks is appropriate to delegate to an LPN?

Performing suctioning on a client who has a tracheostomy

A nurse notes a new prescription in a client's medical record for oral digoxin (Lanoxin) 12.5 mg to be given daily. The nurse questions the dosage of the prescription, and the provider confirms the dosage as written. Which of the following actions by the nurse is appropriate?

Clarify the prescription with the nursing supervisor

A nurse manager is developing a new policy to improve how shift assignments are made. To decrease resistance to the change, which of the following actions should the nurse take first?

Determine which nurses are likely to support the proposed change.

A home health nurse is scheduled to visit four clients. Which of the following clients should the nurse visit first?

A client who has diabetes mellitus and has recently started giving self injections of insulin 3 times a day

A nurse is caring for a client who was admitted after a suicide attempt, and has not yet been evaluated by a mental health provider. The client wants to leave the hospital against medical advice medical advice, but his wife is opposed. Which of the following is an appropriate response by the nurse to the to the wife?

"We cannot make him stay in the hospital if he has decided to leave"

A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality?

Tell a client's partner that the result of his wife's laboratory tests cannot be disclosed without her permission. 

A nurse is caring for a client who has end-stage alzheimer's disease and has a prescription for the insertion of an NG tube for enteral feedings. The client's living will indicates that artificial nutrition should not be instituted. Which of the following actions should the nurse take first?

Speak with the clients provider

A nurse is caring for a patient who is having acute withdrawal from alcohol and is attempting to harm other clients and staff. Which of the following actions should the nurse take first?

1) Place the client in four point restraints

2) Obtain a written order for restraints from the provider

3) Instruct a staff member to stay with the client

4)Assess the client every 15 to 30 minutes

5) Document the client's response to the intervention

A nurse working on the maternal newborn unit is caring for an infant whose mother has a history of substance abuse. The mother tells the nurse that she is afraid that she will relapse and start using drugs again. Which of the following actions should the nurse take?

Contact social services for a consultation

A family member of a client faints after being informed by the provided of the clients death. the family strikes his head on the floor during the fall. Which of the following actions should the nurse take first?

Check the family member for a patent airway

A nurse is developing a plan of care for a preschooler whose family is homeless. Which of the following assessment findings is the highest priority for the nurse to investigate?

The child has inflamed fissures at the corners of her mouth.

A nurse on a skilled unit is caring for a client who had a cerebrovascular accident. The client is experiencing residual aphasia, dysphagia, and right sided hemiparesis. Which of the following staff should participate in an interdisciplinary conference to develop the client's rehabilitation plan? (Select all that apply) 

Physiatrist

Speech language pathologist

Occupational Therapist

A charge nurse on a medical-surgical unit is making client care assignments. When delegating tasks to an RN and a licensed practical nurse (LPN), which of the following tasks must be completed by the RN?

Initiating a dietary referral based on a clients HbA1c 

A nurse is reviewing preoperative procedures with a newly licensed nurse. The nurse should recognize that the newly licensed nurse needs further teaching when he states that the RN's responsibilities for informed consent include?

Describing potential complications of the surgical procedure

A nurse is preparing to give a medication to a client. Which of the following are appropriate client identifiers for the nurse to use? (select all that apply

-A photograph of the client

-A wristband bearing the client's name

-A number assigned by the facility

-The client's birthdate

A nurse is precepting a newly licensed nurse who is caring for a client who has suspected tuberculosis. The nurse should instruct the newly licensed nurse that standard infection control procedures in this situation include?

Wearing a particulate respirator masks

Which of the following demonstrates safe, cost-effective care?

Using the inner surface of a glove package as a sterile field.

A nurse has programmed an IV pump to deliver oxytocin (pitocin) to augment labor. The nurse thinks that the IV pump is malfunctioning. Which of the following are appropriate actions for the nurse to take? (Select all that apply)

- Obtain another IV pump

-Place the infusion on hold

-Tag the pump as faulty

A nurse manager on a med-surgical unit has been asked to implement evidenced based changes to improve performance of staff in regard to indwelling catheter care. Identify the sequence of actions the nurse manager should take to implement effective change strategies:

1) Educate the staff to gain support for the changes

2)Identify areas of resistance to the needed changes

3) Set target dates for the implementation of changes

4) Require compliance with the changes

A nurse manager is planning to conduct annual performance reviews for a staff nurse. Which of the following strategies should the unit manager include in the review process?

Have the nurse complete a self-appraisal prior to the interview

A home health nurse is planning her daily visits and receives laboratory results for four clients. The nurse should first see the client with which of the following laboratory values?

A charge nurse is developing an educational plan to ensure that staff members are aware of their legal responsibilities. Which of the following should the nurse do first when developing the plan?

Assess the staff nurses' current level of knowledge about legal responsibilities

A charge nurse is notified that three office workers who have been exposed to Bacillus Anthracis are being transported to the emergency department. The charge nurse should instruct the nursing staff to implement which of the following measures?

In the middle of the shift, a staff nurse becomes angry and leaves the facility. Which of the following actions should the charge nurse take first?

Check the status of the clients who were assigned to the nurse

A client who is terminally ill is experiencing renal failure and requests no further intervention. The primary care provider has prescribed renal dialysis that is to begin tomorrow. Which of the following actions should the nurse take?

Discuss the client's request with the primary care provider

An occupational health nurse is triaging clients at the site of an industrial explosion. A class III, or green tag, should be assigned to the client with which of the following manifestations?

A staff nurse is planning an educational program to improve the competence of the staff on the telemetry unit in interpreting ECGs. The first step the educator should take is to?

Identify significant arrhythmias that the nursing staff should be able to recognize.

A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurser take?

Report this issue to the nurse manager

A client has a consultation from a surgeon in the emergency department. The next day the client indicated to the nurse that the surgeon was rude, and the client asks for a different surgeon. Which of the following is the appropriate action for the nurse to take?

Contact the nursing supervisor to see what other options are available.

A nurse has just received report on four clients on a medical-surgical unit. Which of the following clients should the nurse plan to assess first?

A client who is postoperative following a total knee arthroplasty and has a capillary refill of 6 seconds

There has been a massive community disaster and stable clients must be discharged from the hospital to prepare for the influx of new casualties. Which of the following clients is safe to discharge?

A client with multiple sclerosis who reports ataxia

A nurse administrator is reviewing the quality improvement process with a nurse manager who has been newly hired on a unit that is below the benchmark in medication administration. The nurse administrator should recognize that further teaching is required when the newly hired nurse uses which of the following to gather additional data about medication administration on the un it?
I'm

Which client should the postpartum nurse assess first after receiving the AM shift report?

Which client should the nurse assess first?

Can a UAP bathe a patient on telemetry?