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A nurse on a medical-surgical unit is delegating tasks to nursing team members. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Instructing a client how to use a glucometer B. Instilling lubricating eye drops for a client C. Evaluating the effectiveness of a client's pain medication D. Transferring a client who is postoperative from a bed to a chair - - correct- - D. Transferring a client who is postoperative from a bed to a chair Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, and other simple procedures that do not involve assessment or teaching. Incorrect Answers: A. The nurse should not delegate tasks that involve teaching to an AP. B. The nurse should not delegate tasks that involve medication administration to an AP. C. The nurse should not delegate tasks that involve assessment to an AP. /
A nurse is caring for a client who received a sedative-hypnotic medication at bedtime. The client gets out of bed and falls, sustaining a laceration that requires suturing. Which of the following statements should be included as part of the nurse's documentation in the client's chart? A. "Client found sitting on floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified." B. "Client found sitting on floor with blood running down face. Side rails had not been raised by assistive personnel when client was placed in bed." C. "Client fell due to confusion caused by sleeping medication." D. "Client got out of bed and fell, despite being told to call for assistance when ambulating." - correct- - A. "Client found sitting on floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified." This statement is appropriate to include in the documentation. It presents objective facts and assessments related to this event. The nurse should also include vital signs, further assessments, the name of the provider notified, treatments or procedures that were done per the provider's prescription, and the client's response. Incorrect Answers: B. This statement is not appropriate to include in the documentation because it includes a nondescript comment that is open to interpretation. Blame is also placed on the assistive personnel for not putting up the side rails. C. This statement is not appropriate to include in the documentation because it draws a conclusion about why the client fell. Although sedative-hypnotic medications can cause confusion, it is inappropriate to assume that the medication caused the fall.
A nurse is preparing to transfer an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse plan to take? A. Discuss the client's long-term recovery goals with him B. Discuss the client's nursing care needs with his provider C. Give a written summary of the client's nursing plan of care to the long-term care facility D. Review the client's nursing care plan with his family members - - correct- - C. Give a written summary of the client's nursing plan of care to the long-term care facility A written summary of the client's nursing plan of care will convey his needs to the nurses who will be working with him in the long-term care facility. Incorrect Answers: A. Clients should always be informed participants in their plans of care; however, the nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. B. This is not needed, even for clients who will continue to use the same provider. The nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. D. The client's family members should always be participants in the plan of care with his consent; however, the nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. //
A charge nurse is observing a group of newly licensed nurses. Which of the following actions should the charge nurse report to the nurse manager as a violation of HIPAA? A. Assigning a client who requested a private room to a semi-private room due to unavailability B. Placing a client who is confused in restraints C. Talking about clients with other nurses in the cafeteria D. Wheeling a client who is wearing a sheet down the hall into the shower room - - correct- - C. Talking about clients with other nurses in the cafeteria The nurse should not discuss information about clients—including their personal concerns, diagnoses, and treatments—with anyone who is not directly involved in the client's care. Doing so is a violation of HIPAA regulations. Nurses should take special care not to compromise this right by discussing client care in such places as elevators, restaurants, or other areas that are accessible to the public in which the discussion might be overheard. Incorrect Answers: A. While this is an unfortunate circumstance, it does not violate HIPAA regulations. If no private rooms are available, the nurse should assign the client to an available room and plan to move the client when a private room becomes available. B. Placing a client in restraints is not a violation of HIPAA regulations. However, this action could be considered false imprisonment if it is done without first taking other measures to ensure the client's safety. D. Although wheeling a client who is wearing only a sheet down the hall could be an invasion of personal privacy, it is not a HIPAA violation. The Privacy Rule associated with HIPAA addresses the use and distribution of personal client information. Nurses should take care to expose clients as little as possible to maintain their privacy. /
B.
Recommend that the employee review the facility's policy regarding absences. C. Inform the employee in writing about the facility's employment policy. D. Ask the employee for a written action plan after discussing the reasons for these absences. - correct- - A. Verbally remind the employee about the facility's employment standards. Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior. Incorrect Answers: B. Recommending that the employee reviews the policy does not ensure that the employee will read and fully understand the employment standards. C. Written admonishment is the second step in the disciplinary process for this type of infraction. If the employee fails to make a positive behavioral change after being verbally reminded by the manager about the facility's employment standards, the nurse manager should inform the employee in writing. D. This is an example of performance-deficiency coaching, which the nurse manager should use to correct unacceptable behaviors over time. /// A nurse is caring for a child who has sustained extensive head injuries. The provider has diagnosed brain death. Which of the following statements should the nurse use to begin a conversation about the option of organ and tissue donation with the child's parents?
B.
A. "I want to talk to you about the importance of considering the donation of your child's organs for transplantation." "I want to give you some information about an option that you have regarding donating your child's organs to others who are in need." C. "I am legally required to inform you that you can donate your child's organs for transplantation." D. "Have you ever considered donating your organs for transplantation?" - - correct- - B. "I want to give you some information about an option that you have regarding donating your child's organs to others who are in need." This is an appropriate statement to begin the discussion. It clearly conveys the nurse's intention to give the family factual information and does not make any emotionally-laden statements. Incorrect Answers: A. This is a strong statement of the nurse's belief that organ donation is the right thing to do. It is not appropriate to make the family feel guilty if they choose not to donate. C. This focus on a legal requirement might imply that the nurse does not support the idea of organ donation. The nurse should avoid statements that lead the family one way or another. D. Asking the family members about their thoughts on donating their own organs shifts the focus away from the immediate situation. / A nurse is assisting with the informed consent process for a client who is scheduled for a belowthe-knee amputation. The client asks the nurse, "Why are they making me have this
B.
D. Explanation of a surgical procedure is part of the informed consent process, which does not fall within the nursing scope of practice. Informed consent is part of the provider-client relationship. Even though the nurse assumes responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent. The nurse's signature only indicates that the client voluntarily gave consent, the client's signature is authentic, and the client appears to be competent to give consent. //
A nurse is admitting a client who has active gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)? A. Obtain the initial set of vital signs B. Listen for bowel sounds C. Show the client how to use the nurse call light D. Ask the client if he has any allergies - - correct- - C. Show the client how to use the nurse call light The AP can show the client how to use the nurse call light, as this task does not require an assessment of the client first. Incorrect Answers: A. The nurse should not delegate obtaining the initial set of vital signs to an AP. The nurse must assess the client prior to delegating tasks to determine if the client is medically stable. B. This is an essential assessment for this client, but it is not within the AP's scope of practice. D. Asking the client if he has any allergies is a part of the admission assessment and is not within the AP's scope of practice. / A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? A. Call the clients' family members to provide additional help with moving the clients.
C. Present the information at a tenth-grade reading level D. Use 12-point font size - - correct- - A. Allow frequent rest periods during teaching The nurse should allow frequent periods of rest since an older adult client processes information more slowly. Incorrect Answers: B. The nurse should use white or buff-colored paper with a matte finish to avoid glare. C. The nurse should present the information at a sixth- to eighth-grade reading level. D. The nurse should use at least a 14-point font size for an older adult client when developing written materials. / A nurse is creating a plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. Baked pork chop B. Cheeseburger C. Ham and cheese omelet D. Grilled salmon - - correct- - D. Grilled salmon
The nurse should recommend grilled salmon for a client who observes Kosher dietary laws. Grilled salmon is a fish with fins and scales, which can be consumed. Seafood with shells, such as lobster or crab, is prohibited. Incorrect Answers: A. A baked pork chop is a source of pork, which is prohibited by Kosher dietary laws. B. A cheeseburger contains both meat and dairy products, which may not be eaten at the same time and is prohibited by Kosher dietary laws. C. A ham and cheese omelet contains pork, which is prohibited by Kosher dietary laws. / A nurse is transporting a client to the surgical suite for a procedure. The client tells the nurse he no longer wants to have the surgery. Which of the following responses should the nurse make? A. "Let me call your surgeon while you tell me about your concerns." B. "You should talk to your family before you make this decision." C. "I'll ask your surgeon to speak to you as soon as you are in the surgical suite." D. "Everything will be fine. The operation will be over soon, and you will be glad you had it done." - - correct- - A. "Let me call your surgeon while you tell me about your concerns." The client has the right to refuse treatment. Speaking with the nurse and the provider about concerns or questions could relieve anxieties and allow the client to continue with the procedure. Consent may be withdrawn after being given. It is the nurse's responsibility to notify the surgeon if the client verbalizes a desire to stop or delay a medical procedure or treatment.
Incorrect Answers: A. Critical pathways address appropriate nursing care and actions that other disciplines are responsible for as well. They provide a holistic approach to the plan of care. B. Critical pathways are not legal documents. Critical pathways establish the standard of care in an institution, but variances from the pathway often occur for multiple reasons. Documentation of these variances is important, along with the revised plan to correct or address the variance. D. Critical pathways are developed for individual diagnoses. They are based on the typical interdisciplinary needs and length of stay for that particular diagnosis. /// A nurse is caring for a client with stage 4 ovarian cancer who has decided to stop treatment and enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the client in her decision? A. Responsibility B. Accountability C. Advocacy D. Confidentiality - - correct- - C. Advocacy By following the ethical principle of advocacy, the nurse supports the client in the decisions she makes about her own health care.
Incorrect Answers: A. By following the ethical principle of responsibility, the nurse upholds obligations. B. By following the ethical principle of accountability, the nurse answers for personal actions. D. By following the principle of confidentiality, the nurse protects the client's privacy and health care information. / A school nurse is assessing a child who has multiple bruises on his trunk and extremities. The child reports falling out of a tree 2 days ago. The nurse's assessment findings show patterns of bruising that are not typically sustained during a fall from a tree. Which of the following actions should the nurse take? A. Report the findings to local police and social service agencies. B. Report the findings to the school district superintendent. C. Call the parents of the child and further assess the causative event. D. Reassess the child on a weekly basis for injuries. - - correct- - A. Report the findings to local police and social service agencies. Health care providers are required to report suspected child abuse. The nurse's primary concern is the safety of the child. Procedures for reporting differ in various locations, but procedures involve notification of police and social services personnel who can investigate the situation. Incorrect Answers:
Incorrect Answers: A. This 3-year-old client is at risk for developing an infection if the dressings are not kept intact and clean. Children who are otherwise healthy are extremely mobile and generally experience optimal healing. Therefore, another client is at greater risk for a complication. C. This 30-year-old client is at risk for developing compartment syndrome if an excess amount of swelling develops. Excess swelling is rare but can restrict blood flow to the extremity and cause nerve damage. Therefore, another client is at greater risk for a complication. D. This 42-year-old client who has an indwelling urinary is at risk for developing a urinary tract infection but only as a result of possible contamination from poor technique during insertion of the catheter or contamination during catheter care. Therefore, another client is at greater risk for a complication. / A group of nurses on a telemetry unit informs a nurse manager of a need to update the cardiac monitoring system to improve arrhythmia detection. Which of the following responses should the nurse manager make? A. "This purchase will require the completion of a variance analysis." B. "This purchase will need to be addressed in the capital budget plan for the unit." C. "This purchase will result in a reduction in the operating budget." D. "This purchase can be reimbursed by Medicare funds, as clients who use Medicare will benefit from the equipment." - - correct- - B. "This purchase will need to be addressed in the capital budget plan for the unit."
The capital budget involves planning for spending related to equipment and major purchases that have a long life of use. Incorrect Answers: A. The anticipated purchase of new equipment does not require a variance analysis. Variance analysis is a process that differentiates planned budget results from actual results. C. An operating budget is separate from the budget for large expenditures for equipment or other major purchases. This type of budget reflects expenses that change in response to the volume of service (e.g. supplies, electricity). D. Medicare funds do not reimburse institutions for equipment purchases, even though clients who are receiving Medicare use the equipment. /// A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict-resolution styles is an example of one nurse putting aside personal goals to satisfy the other nurse? A. Avoidance B. Accommodation C. Compromise D. Collaboration - - correct- - B. Accommodation
