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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 charge nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates the teaching was effective? "There must be documentation in the medical record about whether a client has advance directives." A nurse in a long-term care facility is transferring a client to an acute-care facility. Which of the following information should the nurse include when transferring? List of current medications A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take? Pick up the first sterile glove by grasping the folded cuff edge A nurse has just received a 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 4 seconds A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first? A client admitted for a fractured hip who has developed slurred speech A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "Clients on a mental health unit can refuse their medication."
When participating in the informed consent process prior to surgery, which of the following actions should the nurse take? Review previously provided information about the procedure A nurse is teaching a newly licensed nurse about using electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "My access to client electronic records might be tracked by my nurse manager." A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include? Raise the footplates of the wheelchair before transferring the client A nurse is presenting information on health care law to a group of newly licensed 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 charge nurse on a medical unit hears the fire alarm and announcement that a fire is occurring on the unit. Which of the following is the priority action by the charge nurse? Instruct ambulatory clients to go to a safe area A nurse manager is reviewing client care needs. Which of the following actions should the nurse take when making client care assignments? Select all that apply. Delegate provider prescription received for client 1 to a registered nurse, delegate provider prescription received for client 3 to a practical nurse, delegate provider prescription received for client 4 to an assistive personnel A charge nurse is assessing a client in a long-term care facility. Which of the following findings indicate that a referral for a speech pathologist is needed? Select all that apply. Speech coordination findings, cough findings, vocal characteristics during mealtime, observation of food pocketing There has been a community disaster and stable clients must be discharged from a facility to prepare for the influx of new casualties. A nurse should identify that which of the following clients is safe to discharge? a client who has multiple sclerosis and reports ataxia A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A client who has peripheral vascular disease and has an absent pulse in the right foot
A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent? Ask the client to explain the procedure that is being performed A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make? "Your case manager will coordinate the resources you will need." A grandparent brings their 15-year-old grandchild to the emergency department reporting that they have severe abdominal pain and are scheduled for an immediate appendectomy. The nurse confirms that the client's guardians are unavailable. Which of the following actions is appropriate? Have the grandparent sign the consent form A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions? Wear an N95 respirator mask when in the client's room A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn? Home health 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 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 on a medical-surgical unit is making assignments for the next shift. A licensed practical nurse (LPN) and an 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 is observing an assistive personnel (AP) 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 nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first? Perform a chart review to gather data about the clients who developed infections
A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of causalities. Which of the following clients should the nurse recommend the provider evaluate first? A client who has a sucking chest wound A nurse is caring for four clients. Which of the following tasks can the nurse assign to an assistive personnel (AP)? Perform chest compressions on a client who is in cardiac arrest 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 assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)? Determine a client's intake and output A charge nurse is observing a newly licensed nurse care for a client who has a prescription for application of an aquathermia pad to the right lower leg. Which of the following actions should indicate to the charge nurse that the nurse understands how to use the device? Select all that apply. Asks the client to report if the aquathermia pad gets too warm, ensures that the client's call light is in reach 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 newly licensed nurse indicates an understanding of the instructions? "After I finish with the printout of my assignment, I'll put it in the shredder receptacle." A nurse is caring for a client who speaks only Spanish and is to undergo hip arthroplasty the next day. The client's child speaks English and is in the room with them. Which of the following actions should the nurse take? Select all that apply. Use a Spanish/English medical dictionary to assist with communication, enlist the help of the bilingual assistive personnel (AP) assigned to the client, request that the hospital's Spanish interpreter help the nurse provide education 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 II (green tag) clients 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?
Observe the parent securing the newborn into the infant care seat in the parent's car A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse take? Select all that apply. Role model a positive approach to the changes, encourage staff members who support the changes to discuss the issue with resistant staff A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? Select all that apply. The right to be treated with respect and dignity, the right to refuse their medications, the right to leave regardless of provider recommendations, the right to be fully informed of their health conditions A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease? Chlamydia trachomatis A charge nurse is delegating tasks on nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the charge nurse take? Assign the procedure to a licensed practical nurse (LPN) A nurse is developing a plan of care for a school-age child whose family is without housing. Which of the following findings should the nurse identify as the priority? The child has red fissures at the corners of the mouth A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference? The client refuses to attend physical therapy sessions A nurse is caring for a client who has a tumor, the provider recommends surgery. the client refuses but clients partner wants it. Which of the following determines if the surgery will be done The clients partner is the durable power of attorney Client understands risk and refusing Clients refusal Ethics commity client understands risk and refusing New diagnosis of chlamydia Report to local health department Initiate contact precaution Use condoms Apply antiviral
report to local health department A nurse is caring for a client who has cancer, the client's adult child asks the nurse for info about treatment plan. How should nurse respond? Speak to mother Provider will speak with you I cannot provide without consent What would you like to know about it? i cannot provide without consent A nurse is assessing an older adult client who was brought to the ER by his adult son, reports he fell at home. Nurse suspects abuse, action to take? Treat / discharge File incident report Ask client about injuries while son is present Ask son to go to waiting area ask son to go to waiting area A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct to apply to a client who has full thickness burns over side of body a. Red b. Yellow c. Green d. Black black A nurse on a med surg unit is caring for a client who asks about advance directives and wants to appoint a health care proxy. Which of the following responses should the nurse make? Choose a family member Attorney Decisions when you are unable to do so Appoint before undergoing procedure decisions when you are unable to do so A hospice nurse is caring for a client who has a terminal illness. Reports severe pain, prescribed meds, difficult to arouse. Nurse should a. Continue opioid Contact provider Administer benzo Without opioid Continue the medication dosages continue the medication dosages
contact case manager A nurse is providing COS report for oncoming nurse. Nurse should include Local banks Vital signs as prescribed Radiology for xray Clients partner came 2 hours ago Clients partner came 2 hours ago A nurse in er is preparing for client who arrived via ambulance, disoriented, cardiac arrythmia, action for nurse High risk manager Clients next of kin Client sign Proceed with procedure without consent proceed with procedure with consent A nurse is preparing to dc client who requires home oxygen, company has not delivered tank Notify provider about delay Contact social services Instruct family to contact insurance provider Send one home from facility contact social services A nurse from med surg caring for group of clients, delegate to LPN? Urine specimen from older adult client Wound debridement to PT Postmortem care Reinforce dietary teaching for heart disease urine specimen from older adult client Manager leading discussion on ethical dilemmas, example Minor burn from coffee Operation on wrong side of body Parent wants teen to receive radiation against will Rn witnesses another rn give incorrect med parents wants teen to receive radiation against will nurse develops dc plan for postop and needs wheel chair. refferral? home health caring for client who asks about prevalence of disease, rn obtains info by evidence based journal
rn completed electronic record, ap finished vitals log out so ap can log in nurse is preparing teaching for a different language, intervention interpreter a nurse is preparing to transfer to facility, include what info for cos report the time the client received last pain med dose nurse on inpatient care unit work to reduce costs, cost containment plan use clean gloves rather than sterile gloves for colostomy care incident report for medication error include time med occurred preparing client for elective mastectomoy, want to wear wedding band place with clothing med surg unit, evaluating ap infection control actions, correct use of precautions removes gloves before leaving room mrsa education program for staff regarding new iv pump, sequence of actions schedule different sessions client rights inservice responsible for informing client about tx options receiving rx from provider for client with increased pain, add to medical record iv prn for pain rn caring for client who reports acute pain but refuses im medication, distracts client and quickly administers med, illustrates which of the following battery dc teaching to parents of toddler with asthma, unable to afford nebulizer for client, recommend social worker newly licensed nurse on isolation precautions, understanding ambulatory client wear mask when outside charge nurse on ob unit, client for rn floating from med surg primigravida, 1 day post op c section
assessing client who had meningitis, tell provider immediately decreased loc preparing client for surgery, client signed consent but is not concerned about the pain i understand and its not too late to change caring for client with anorexia, disciplinary teams for consultation sata nutritional therapist mental health case manager assessing client post op following left leg below the knee amputation, statement showing need for referral for occupational theapist taking care of a toddler at home nurse is caring for client who wanders halls, action nurse to take administer sedative preparing delegation for bathing end stage lung cancer data collected specific needs related to turning nurse in a long term care facility fall prevention includes institute rounds q2 hours to offer toileting nurse enters hallway and sees visitor looking at client medical record info close tab teaching new nurse about confidentiality, nurse should include which of the following that represents violation of confidentiality providing copy of client's medical record to paramedic A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first? d. 39 has negative contraction stress test nurse working on quality improvement team that is assessing an increase in client falls at facility, nurse should include as quality improvement id those at risk for falls med surg unit caring for 4 clients, schedule interdisciplinary conference for the following fluid risk new nurse has trouble focusing and difficulty completing care for assigned clients
take time to plan at beginning of shift case manager preparing dc for client with coronary artery bypass surgery limited social support nurse enters client room for witness of signed consent inform provider that client needs additional clarification charge notices 2 staff aren't taking meal breaks, action to take determine reasons the nurses are not taking scheduled breaks client reports ap positioned him with excessive force contact nurse manager client with type 1 dm, client wants to go home sign an ama charge making staff assignments on med surg unit, delegate to ap measuring 02 er nurse assessing client unconscious following mv crash, client requires immediate surgery, action to take transport to operating room without verifying informed consent 4 clients, assess first post op
