Nursing Scenarios and Best Practices, Exams of Nursing

Download Nursing Scenarios and Best Practices and more Exams Nursing in PDF only on Docsity! EVALUATED ATI LEADERSHIP QUESTIONS AND ANSWERS Nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include? - CORRECT ANSWER -The purpose of medication reconciliation is to prevent adverse medication reactions. Caring for a client who falls in his room. Nurse assesses the client, notifies provider, and completes incident report, which action should the nurse take next? - CORRECT ANSWER -Submit the incident report to the risk manager. Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which client should be recommended for discharge? - CORRECT ANSWER -A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy. AP comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following is appropriate? - CORRECT ANSWER -There is a higher risk of infection for our clients associated with artificial nails. Nurse has several tasks to delegate to an assistive personnel. Which of the following tasks should the nurse ask the AP to perform first? - CORRECT ANSWER -Take an arterial blood gas specimen to the laboratory. Nurse manager is reviewing the admission history of four adults who were admitted to the med/surg unit during the shift. which situation is the nurse required to disclose information to an outside agency about the client & circumstances? - CORRECT ANSWER -A dependent adult admitted for the treatment of a spiral fracture. An AP tells the manager that she observed a nurse on the unit removing morphine from syringes prior to administering the medication to clients. Which action should the manager take first? - CORRECT ANSWER -Gather data about the nurse's work performance and attendance history. Client with severe head injury and is declared brain dead. Transplant coordinator has spoken to family about organ donation. Client's spouse is confused and doesn't know what to do. What is the appropriate response? - CORRECT ANSWER -What do you think your spouse would have wanted ? Which lab finding requires follow up? BUN 15 mg/dL Platelet count 60,000/mm3 WBC 6,000/mm3 Hemoglobin 14 g/dL - CORRECT ANSWER -Platelet count 60,000/mm3 Older client with terminal illness and ventilator dependent. Client is A&O and wants to discontinue ventilator. Continued treatment against the client's wishes is a violation of? Veracity Autonomy Fidelity Justice - CORRECT ANSWER -Autonomy Nurse prepares a soap suds enema to a client with constipation. Nurse explains procedure and client states "Doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? - CORRECT ANSWER -Check the client's medical record for the providers prescription. Manager is reviewing Good Samaritan laws with a group of newly licensed nurses. Which statement is appropriate? - CORRECT ANSWER -"If you render aid in an accident, do not leave the scene until another competent person can take over." *Transferring client to discharge location *Maintaining a client tracking system - CORRECT ANSWER -Transferring client to discharge location. Place the steps in order for fire emergency. *Pull the fire alarm *Confine the fire *Extinguish the fire *Rescue the clients - CORRECT ANSWER -Rescue the clients. Pull the fire alarm. Confine the fire. Extinguish the fire. Which situation would the nurse complete an incident report? +Nurse ID's broken piece of equipment +Staff member doesn't show up for their shift. +Client discovers that his dentures are missing. +Nurse has a disagreement with supervisor about inadequate staffing. - CORRECT ANSWER -Client discovers that his dentures are missing. Charge nurse notes a staff nurse delegates an unfair share of tasks to the AP and the nurses on the next shift report the staff nurse frequently leaves tasks uncompleted. Which statement should the charge nurse make to resolve this conflict? - CORRECT ANSWER -I need to talk to you about unit expectations regarding delegating and completing tasks. Nurse is working with an AP to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? - CORRECT ANSWER -Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate. Nurse on med/surg is planning to delegate tasks to an adult volunteer. Which task should the charge nurse avoid assigning to the volunteer? - CORRECT ANSWER -Observing a postoperative client who is confused. Nurse is providing care for a surgeon on a med/surg unit. A nurse from a different unit asks about the surgeon's medical diagnosis. Nurse responds that he is unable to provide the info. Nurse displays which ethical principles? +Utility +Paternalism +Justice +Nonmaleficence - CORRECT ANSWER -Nonmaleficence Client fell and broke hip while being assisted to the bathroom and says he is going to sue the nurse. The nurse knows that in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? - CORRECT ANSWER -Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. Nurse puts in for a promotion and the hiring manager insinuates that if there was a sexual relationship between the two of them, the nurses promotion would get increased consideration. Which of the following actions should the nurse take? - CORRECT ANSWER -Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. A nurse and experienced LPN are caring for clients. Which tasks can the LPN do? - CORRECT ANSWER - Obtain vital signs from a client who is 6 hrs post op. Administer a tap water enema to a client who is preop. Catheterizing a client who has not voided in 8 hrs. (Incorrect answers are Providing discharge instructions to a confused client's spouse & Initiating a plan of care for a client who is postop from appy.) Client has been taking warfarin at home and lab value shows INR of 3.5. She wants to check herself out and refuses to wait until her provider can discuss the situation. What action does the nurse take? - CORRECT ANSWER -Explain the risk the client faces if she leaves the facility. Client 6 hr postop from total hysterectomy. What part of the SBAR includes oxygen saturation and apical heart rate? - CORRECT ANSWER - Assessment Caring for preop patient. Nurse signs as a witness on the client's consent form. Nurse signature on the consent form indicates which of the following? - CORRECT ANSWER -Confirms the client appears competent to provide consent. Health Care Proxy -- which statement needs clarification? - CORRECT ANSWER -I have to choose a family member as my health proxy. When planning delegation of tasks to AP, a nurse considers the 5 rights of delegation. Which of the following should the nurse consider when using one of the 5 rights? +AP ability to prioritize +AP has knowledge & skill to perform task +AP rapport with clients +AP ability to complete task without assistance - CORRECT ANSWER -AP has knowledge & skill to perform task Nurse should delegate collection of which of the following specimens to the AP? +Nurses and other emergency medical personnel - CORRECT ANSWER -Nurses and other emergency medical personnel Which statement b the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to AP? - CORRECT ANSWER -The client's BP and pulse have been fluctuating throughout the day. Nurse manager preparing for inservice program for the nurses on the unit about the new infusion pump. Which teaching strategies is most effective? - CORRECT ANSWER -Demonstrate using the device and observe the staff returning the demonstration. Home health nurse is planning care for a client with Alzheimer's. The partner is primary caregiver and reports no having enough time to complete his errands. Which referral should be made? +Hospice Care +Restorative Care +Mental Health Care +Respite Care - CORRECT ANSWER -Respite Care A nurse is triaging clients following a mass casualty event. Which client is emergent? +punctured femoral artery +multiple fractures +red rash over abdomen +severe flank pain radiating to the groin - CORRECT ANSWER -punctured femoral artery Manager received client request not to have a specific staff nurse care for her while at the facility. Which is the appropriate action? - CORRECT ANSWER -Address the concern with the specific staff nurse. Charge nurse is providing inservice for staff nurses on the use of new IV pumps. Which is the best way to evaluate staff competency with the new equipment? - CORRECT ANSWER -Allow time during the workday when each nurse can demonstrate proficiency. The nurse should delegate meal assistance of which of the following clients to the AP? +lumbosacral spinal tumor +Guillain Barre Syndrome +ALS (amyotrophic lateral sclerosis) +Systemic sclerosis - CORRECT ANSWER -Client with lumbosacral spinal tumor (client not at risk for dysphagia) Nurse checks with AP on the unit throughout the shift to determine if they are completing tasks. This is which rights of delegation? - CORRECT ANSWER -Right Supervision Charge nurse hears provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which statement is appropriate? - CORRECT ANSWER -It must be very frustrating when you don't have what you need to perform the procedure. Manager is preparing inservice program about managing conflict for the nurses on the unit. Which is an example of interpersonal conflict? - CORRECT ANSWER -An experienced nurse is uncivil to a newly licensed nurse. (Interpersonal conflict arises from differing goals and value systems. Ex. incivility and bullying) Triaging clients following a mass casualty event. Which should be assessed first? - CORRECT ANSWER -A client who has severe respiratory stridor and deviated trachea. Preparing to witness informed consent for a client who is preoperative. Client asks "Are there other options besides surgery?" Which response is appropriate? - CORRECT ANSWER -Have you discussed other treatments with your provider? Manager is providing an inservice program about delegation to AP with staff nurses on the unit. Which indicates understanding? - CORRECT ANSWER -The nurse should consider APs level of experience when making delegation decisions. Charge nurse is discussing disaster response with nursing staff. Which indicates an understanding of the Hospital Incident Command System (HICS)? - CORRECT ANSWER -HICS identifies facility responsibilities and channels of reporting. Nurse providing discharge teaching for a client who has a new prescription for home oxygen. Which instructions should the nurse include? - CORRECT ANSWER -Do not adjust the oxygen flow rate. (Other info from the question that I didn't know.) +check oxygen system daily +store unused oxygen tanks upright +avoid wool or materials that can generate static electricity to reduce the risk of fire. Nurse in ED receives report from an emergency responder who states a client is being transported following exposure to "dirty bomb". Nurse should prepare to care for a client that has been exposed to which of the following types of agents? - CORRECT ANSWER -Radiologic (Dirty bomb combines radiologic agents with an explosive device, resulting in immediate effects of radiation exposure.) Nurse finds a client did not receive a scheduled dose of furosemide (Lasix). Which would the nurse include in the incident/variance report? +date of incident +name of provider who prescribed the medication +potential adverse effects to the medication Nurse is caring for 4 clients who are 24 hrs post op. Which client is priority? +BG of 110 pre meal, and post meal 160 +wound drainage sanguineous and now serosanguineous +pain of 4/10 and now up to 6/10 +BP at 0800 of 138/86 and at 1200 106/60. - CORRECT ANSWER -BP at 0800 of 138/86 and at 1200 106/60. A nurse is obtaining informed consent from a client who is preop. What actions should be taken? +establish client is able to pay for surgery +explain the surgical procedure to the client +validate the signature is authentic +verify the client understand the surgery +confirm the consent is voluntary - CORRECT ANSWER -+validate the signature is authentic +verify the client understand the surgery +confirm the consent is voluntary Client family member requests to view the client's medical record. What is the appropriate response? - CORRECT ANSWER -"The client must provide permission to share the records with you." Nurse is planning to assign tasks for a group of clients. Which of the tasks should be assigned to AP? +ambulate an older client with hypertension +provide discharge instructions for a client with new skin graft +perform an admission assessment on a client +check a blood product with another nurse prior to admin +weight a client who has heart failure - CORRECT ANSWER -+ambulate an older client with hypertension +weight a client who has heart failure Nurse has assigned client care activities to AP. Which statement indicates a need for assistance in establishing priorities? - CORRECT ANSWER -"I have my assignment and will start with room 1 and work my way to room 10." Nurse is leading a team of nurse managers is planning to make a major announcement. Which nonverbal communication technique enhances the importance of the announcement? - CORRECT ANSWER -Sit in front of the group for the meeting and then stand for the announcement. Charge nurse plans to use effective change strategies when implementing a change in nursing procedure on the med/surg unit. Which actions should the charge nurse take during the moving stage of change? +Assess the problem +Use tactics to alert staff nurses that a change is needed +Evaluate the effectiveness of the change +Set a target date - CORRECT ANSWER -Set a target date. (During the moving stage, the charge nurse should develop the plan for change and set the target date.) A nurse working in an ED is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? +vigorously rub the skin following a decontamination shower +initiate seizure precautions +provide respiratory support with a plastic oral airway +prepare to admin amyl nitrate - CORRECT ANSWER -Initiate seizure precautions. (Sx of sarin gas exposure include neurologic responses including insomnia, impaired judgement, LOC, and seizures.) RN is delegating care activities to a LPN. Which of the following is priority criterion the RN should consider when delegating? +agency policies for LPN +documented experience level of LPN +documented skill level of LPN +State Nurse Practice Act for LPN - CORRECT ANSWER -State Nurse Practice Act for LPN Charge nurse is reviewing the list of tasks that have been delegated to AP by the nurse. Which task should be reassigned to licensed nurse? - CORRECT ANSWER -removing and cleaning the cannula of a client who has a new tracheostomy. Nurse is planning a community diabetes mellitus management program. Which goal should the nurse include in the program? - CORRECT ANSWER -Client will have decreased incidence of foot amputations. Charge nurse is planning to conduct a performance appraisal of staff member on her unit. Which following actions should the nurse take? - CORRECT ANSWER -Provide the staff member with a copy of the appraisal form in advance. Nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first? +notify security +approach the man and ask why he is making copies +inform the nursing supervisor +report the observation to the nurse caring for that client - CORRECT ANSWER -approach the man and ask why he is making copies +reinforcing a client's dressing for the surgical site of an above the knee amputation +reassuring the partner of a client who sustained a closed head injury - CORRECT ANSWER -assessing a client who experiences unilateral calf pain when ambulating Which client should nurse plan to care for first? +needs assistance with a bath +requesting a referral for home health services +asking about his PCA pump that contains morphine +has questions about his new prescription - CORRECT ANSWER -Client asking about his PCA pump that contains morphine. Which tasks should the nurse assign to the LPN and which to the AP? +providing postmortem care for a client +measuring a client's I&O +obtaining a client's weight +inserting a nasogastric tube - CORRECT ANSWER -+AP--providing postmortem care for a client +AP--measuring a client's I&O +AP--obtaining a client's weight +LPN--inserting a nasogastric tube Which client should the nurse plan to assess first? +school age child with DM and requires BG monitoring +infant with pertussis and on oxygen via NC +sickle cell crisis and ready for discharge +toddler with both arms in casts and needs to be fed - CORRECT ANSWER -+infant with pertussis and on oxygen via NC AP refuses to take specimen to the lab. What action should the nurse take? +take speciment to lab +report AP to charge nurse +complete an incident report +ask the AP about her concerns with the assignment - CORRECT ANSWER -ask the AP about her concerns with the assignment Which tasks should the nurse delegate to an AP? +perform wound irrigation for a client +evaluate pain relief for a client following admin of pain medication +measure & record I&O for client +teach a client about low sodium foods - CORRECT ANSWER -measure & record I&O for client Nurse manager is observing care provided by a nurse who is in orientation to the unit. What action should the nurse manager intervene? +uses clean gloves when discontinuing client's IV infusion +empties client's drainable colostomy pouch when 1/3 full +uses client's telephone number as one form of ID when administering medication +opens top flap of a sterile tray toward the body when assisting the provider with thoracentesis - CORRECT ANSWER -+opens top flap of a sterile tray toward the body when assisting the provider with thoracentesis Client has dementia and is A&Ox3 and has advance directives. Client is scheduled for procedure that required informed consent. Who should sign the informed consent? - CORRECT ANSWER -The client (If client is disoriented and not competent, the person who has durable power of attorney should sign informed consent.) Nurse supervising a LPN who is providing care to a client who is post op. Which statements by the client requires follow up? +I do not know how to make the remote control work. +Do you know when I willbe going home? +My dressing was changed earlier this morning. +I have not received any of my medications today. - CORRECT ANSWER -I have not received any of my medications today. Which client should be given to RN, LPN or AP? +requires frequent ambulation +protective isolation +actively dying and requires IV pain meds +3 days postop & requires a dressing change - CORRECT ANSWER -+requires frequent ambulation (LPN/AP) +protective isolation (LPN) +actively dying and requires IV pain meds (RN) +3 days postop & requires a dressing change (LPN) Nurse is preparing to admin a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? - CORRECT ANSWER -Encourage the client to verbalize questions. Family of husband, wife and child is which type of family form? +Extended +Blended +Nuclear +Intergenerational - CORRECT ANSWER -Nuclear