NURS MISCmanagement Latest Exam| Hudson County Community College

NURS MISCmanagement Latest Exam| Hudson County Community College NURS MISCmanagement Latest Exam| Hudson County Community College The nurse has four new admissions. Each client has a prescription for an IV to be started. It is most important for the nurse to start the IV for which client? 1. A client reporting abdominal pain. 2. 3. A client exhibiting poor skin turgor. 4. A client scheduled for surgery. The nurse supervises an unlicensed assistive personnel (UAP). Which tasks does the nurse delegate to the UAP? (Select all that apply.) 1. 2. Prepare an antibiotic injection. 3. Irrigate a client’s wound using sterile technique. 4. Determine the staging of a client’s pressure injury. 5. Apply an elastic bandage. 6. The charge nurse is making client assignments for the nursing team. Which client will the charge nurse assign to the LPN/LVN? 1 A client diagnosed with psychosis. 2 A client receiving chemotherapy. 3 . 4 A client receiving a blood transfusion. . Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.) 1 Client is not provided with advance directives information. . 2 . 3 Client's protected health information is shared with those not participating in client's . care. 4 Client prepares to sell kidney to the highest bidder. 5 . The nurse provides care for clients in the emergency department. Four clients come in at the same time. Which client does the nurse see first? 1 . 2 A 2-year-old with a temperature of 101 °F (38 °C). . 3 A 20-year-old at 8 weeks ’ gestation reporting vaginal spotting. . 4 A 32-year-old reporting nausea and vomiting for several hours. . The nurse provides care to clients on the inpatient psychiatric unit. The nurse intervenes immediately with which client? 1 A client with borderline personality shouts, "I want my pain medication and I want it . now!" 2 A client with anorexia nervosa is seen putting food from her tray into her pocket. . 3 A client with postpartum depression states, "I cannot wait to get home and be with my . baby." 4 . The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.) 1 “I use this magnifying glass when I need to read small print.” . 2 . 3 . 4 . 5 . 6 “I’m not able to get in the bathtub anymore.” . Four clients give birth to their newborns vaginally within a 10-minute period. Which client does the nurse evaluate first? 1 . 2 A primipara who is crying after giving birth to a 9-lb, 6-oz neonate. 3 A multipara who gives birth to a 6-lb, 3-oz neonate and has a recent substance use . history. 4 A primipara who has a personal physical abuse history and gives birth to a 7-lb, 10-oz . neonate. The nurse overhears the nursing assistive personnel (NAP) discussing a client’s medical condition and test results with other clients. Which responses by the nurse are appropriate? (Select all that apply.) 1. “Don’t worry others yet. The tests will be repeated tomorrow.” 2. 3. “I think the client will improve with this new medication.” 4. “Read the medical record silently, please.” 5. A new nurse makes staff assignments for the first time. After completing assignments, the nurse is called to a meeting. When returning to the unit, the new nurse finds extensive assignment changes were made. Which response by the new nurse is best? 1 . 2 “Why did you change the assignments? I was asked to make them today.” . 3 “Changing the assignments makes me appear incompetent. Next time, please ask . first.” 4 “I would appreciate it if you would not make changes in the assignments I make.” . A client seeks emergency care for blood draining from the right ear after being in a motor vehicle crash (MVC). Which action will the nurse take first? 1 Notify the health care provider that the client ’s condition could become critical. . 2 . 3 Ask if the ear hurts. 4 Complete appropriate forms. A client’s adult child greets the home care nurse at the entrance of the client’s home. The adult child asks the nurse about the mother’s condition. Which response by the nurse is appropriate? 1 “I’m not permitted to give you any information about your mother’s condition.” . 2 “I need to assess your mother’s condition before I can provide information.” . 3 “Your mother was prescribed a new heart failure medication that seems to be . helping.” 4 . A client is admitted involuntarily to the psychiatric unit for assaultive behavior toward others. The client demands to leave the hospital today. Which response by the nurse is best? 1 . 2 “You will be able to leave after your health care provider talks to you.” 3 “You will be able to leave after your health care provider talks with your family.” 4 “You can leave at any time after signing an against medical advice form.” The emergency department nursing educator presents an inservice on evidentiary specimen collection in criminal or forensic cases. Which statement made by a participant requires correction by the educator? 1 "Shotgun wadding, bullets, or head shot projections should be wrapped in gauze and . put in a cup or envelope." 2 "It is important to save any gravel, soil, grass, twigs, or glass that are on the victim or . on the sheets used for transport." 3 "Swabs of both dry and moist secretions should be air-dried prior to placement in the . appropriate container." 4 . Which tasks are appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when providing client care? (Select all that apply.) 1 Discuss laboratory results with a client. 2 Change a client’s IV tubing every shift. 3 . 4 Obtain a client’s orthostatic blood pressures. . 5 . The nurse receives change of shift report. Which client does the nurse assess first? 1 A client who had a partial lobectomy and has a chest tube. 2 . 3 A client complaining of a headache for the past hour. . 4 A client in Buck ’s traction for a fracture of the right femur. . The nurse overhears two nursing assistive personnel (NAP) discuss a client’s protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the NAPs work. 3. 4. Notify the hospital risk manager and ethics committee. The nurse notes that the output for a client diagnosed with chronic kidney disease was not documented for the previous shift. Which action will the nurse take first? 1 . 2 Complete an incident report. . 3 Ask the client to provide the amount of output. . 4 Notify the immediate supervisor of the incident. . The nurse receives a phone call from a person who states, “The client in room 203 is my family member. Can you give me a status update?” Which response by the nurse is appropriate? 1 “The client is requiring intravenous pain medications.” 2 “The client is scheduled for a colonoscopy in the . morning.” 3 “The client is receiving aggressive antibiotic therapy.” 4 . The nurse provides care for a client who has undergone a right total knee replacement. Which assessment finding requires immediate intervention by the nurse? 1. The client ’s temperature is 99.4 °F (37.4 °C). 2. The client ’s heart rate is 58 beats/min and regular. 3. The client ’s pedal pulses are palpable, but weak bilaterally. 4. The nurse supervises the unlicensed assistive personnel (UAP). Which tasks can the nurse safely delegate to the UAP? (Select all that apply.) 1 Determine a client’s risk for pressure injury development. . 2 . 3 . 4 Answer questions about a patient-controlled analgesia (PCA) pump. . 5 Change a client’s peripheral intravenous (IV) site dressing. . The nurse on the medical/surgical unit has just received report. Which client does the nurse see first? 1 A 29-year-old female undergoing peritoneal dialysis with outflow that appears red- . tinged. 2 A 35-year-old male diagnosed with acute post-infectious glomerulonephritis with BP . 150/90 mm Hg. 3 . 4 A 56-year-old male diagnosed with angina who is scheduled for discharge today. The nurse supervises care provided by a nursing assistive personnel (NAP). Which actions by the NAP require an intervention by the nurse? (Select all that apply.) 1 The NAP applies nonsterile gloves to empty a client’s urostomy bag. 2 . 3 . 4 . 5 The NAP documents morning vital signs and blood glucose levels obtained from a . group of clients. The oncology nurse is reassigned to the medical-surgical unit. The charge nurse for the medical-surgical unit assigns which clients to the oncology nurse? (Select all that apply.) 1 . 2 Client who will be discharged to home today following total hip replacement 72 hours . ago. 3 Client who requires administration of pain medication after undergoing bariatric . surgery 6 hours ago. 4 Client admitted yesterday who is newly diagnosed with atrial fibrillation. 5 . 6 . The nurse manager makes decisions for the group, gives orders, and is concerned with task accomplishments. Which leadership style does the nurse manager use? 1. Democratic leadership. 2. 3. Laissez-faire leadership. 4. Transformational leadership. The nurse provides care for the client diagnosed with esophageal cancer. Which goals does the nurse establish in the plan of care? (Select all that apply.) 1. Client will experience remission of the cancer. 2. 3. 4. 5. Client will agree to hospice consult. A client being discharged from the postpartum care area requests perineal pads, diapers, wipes, and perineal spray. Which response is the best for the nurse to make to this client? 1. "I will be glad to get these supplies for you." 2. "Why don ’t you stop at the store on the way home?" 3. "I don ’t think that you need any more supplies." 4. The nurse supervises a nursing assistive personnel (NAP). Which task is appropriate for the nurse to delegate to the NAP? 1. Postoperative exercise teaching. 2. Negative pressure wound therapy. 3. Elastic bandage application. 4. The nurse supervises the care of a client receiving enteral feedings through an NG tube. Which observations indicate to the nurse that the care being provided by the nursing assistive personnel (NAP) is appropriate for this client? (Select all that apply.) 1. Aspirates and measures the amount of the gastric aspirate. 2. 3. 4. Measures the pH of the gastric aspirate. 5. Infuses the intermittent feeding in 20 minutes. 6. The nurse manager is presenting information at a staff meeting. When outlining the responsibilities of this position, which statements does the manager include? (Select all that apply.) 1 . 2 “Coordinating client care and follow up with the clients after discharge.” 3 . 4 . 5 “Reviewing incident reports and mitigate risk and liability for the institution.” The nurse is assigned four clients on a medical-surgical unit. During the medication pass at 2100, in which order does the nurse give medications to these clients? (Please arrange in order. All options must be used.) The client prescribed metronidazole 500 mg IV for necrotizing pancreatitis, the client prescribed levetiracetam 750 mg PO for seizure disorder, the client post-exploratory laparotomy who is prescribed famotidine 20 mg IVP, the client reporting mild anxiety who is prescribed hydroxyzine 25 mg PO as needed. The nurse reviews care needed by several clients with open wounds. Which clients will the nurse delegate to the LPN/LVN? (Select all that apply.) 1 . 2 Client newly admitted with a skin tear on the forearm covered by a transparent . dressing. 3 . 4 . 5 Client with a stage 2 pressure injury on the coccyx with new onset of purulent . drainage. 6 . The nurse provides care for a client who reports flank pain. The health care provider (HCP) writes a client prescription that states, “CT scan to rule out cerebrovascular accident (CVA).” Which action does the nurse take first? 1. Assess if the client has metal implants. 2. Determine if the client has peripheral IV access. 3. Ask if the client has an allergy to contrast media. 4. Which client on the pediatric unit requires the immediate attention of the nurse? 1. A client with epilepsy who has a loose tooth. 2. A client experiencing diarrhea with a sickle cell crisis. 3. 4. A client who is blind and has a nosebleed. The nurse on the medical surgical unit receives the shift report. Which client will the nurse see first? 1 A client 1 day postoperative after an appendectomy. . 2 A client who had a detached retina surgically repaired 4 hours ago. . 3 . 4 A client 2 days postoperative after a laminectomy with spinal fusion. The nurse is considered professionally negligent by delegating which task to the nursing assistive personnel (NAP)? (Select all that apply.) 1 Measure a client's temperature rectally. 2 . 3 . 4 . 5 . 6 Administer a cleansing tap water enema. . Which information is essential to report when communicating client information at the change of shift? (Select all that apply.) 1 . 2 . 3 . 4 The client has a 20-year history of smoking. 5 The client receives carvedilol, benztropine mesylate, and losartan on a daily basis. The nurse delegates tasks to the nursing assistive personnel (NAP). For which NAP actions will the nurse intervene? (Select all that apply.) 1 . 2 Reapplies the nasal cannula for a client who displaces the oxygen tubing. . 3 . 4 Reports an abnormal capillary blood glucose value to the nurse. 5 . The nurse reviews proper application of the condom catheter with the nursing assistive personnel (NAP). Which statement by the NAP indicates to the nurse that further teaching is required? 1 “I will clip the hair at the base of the penis before I apply the condom.” 2 . 3 “I will leave 2 inches between the tip of the penis and the end of the catheter.” . 4 “I will secure the urinary drainage collection bag to the bed frame.” . The nurse works under the supervision of a democratic nurse leader planning to institute a new policy for the unit. Which step is the nurse leader likely to take? 1 Encourage staff leadership by generating commitment to the development of a new . policy. 2 Institute a policy based solely on the nurse leader’s preference and experience. . 3 Delay developing a policy until the administrator makes the policy a mandatory . requirement. 4 . The LPN/LVN delegates tasks to the nursing assistive personnel (NAP). The nurse intervenes if which action is observed? (Select all that apply.) 1 . 2 The NAP provides catheter care. . 3 . 4 . 5 The NAP stocks the department with supplies. . 6 . The nurse delegates tasks to a nursing assistive personnel (NAP) for the first time. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. 2. 3. Allow the NAP to decide which client changes to report. 4. Permit the NAP to decide when tasks will be completed. 5. The nurse plans care for a group of clients. Which client will the nurse assign to the LPN/LVN? 1 Client who developed a pneumothorax during an appendectomy. . 2 Client with increased intracranial pressure who only responds to painful stimuli. . 3 . 4 Client being discharged after having a mandibular fracture immobilized by jaw wiring. A nurse from the emergency department (ED) is floated to the surgical unit. Which clients will the charge nurse appropriately assign to the ED nurse? (Select all that apply.) 1 A client with a new diagnosis of heart failure to be discharged in 24 hours. 2 A client who had a cholecystectomy 6 hours ago. 3 . 4 . 5 . A nursing team discusses the new nurse manager’s leadership style. The unlicensed assistive personnel (UAP) states, “The new nurse manager does not give us any direction or supervision.” Which is an accurate response by the nurse? 1 “The nurse manager has an autocratic leadership style. It is best to not challenge the . nursing chain of command.” 2 “The nurse manager has a democratic leadership style. We will vote on all decisions in . staff meetings.” 3 “The nurse manager has a situational leadership style. Direction will be provided . during a crisis.” 4 . The nurse provides care to clients in a skilled nursing facility. Which client requires the nurse's immediate attention? 1 . 2 Experiencing pain after receiving morphine in an acute care facility and was . transferred with a prescription for acetaminophen with codeine. 3 Voiding foul-smelling, cloudy, dark amber urine associated with dysuria. 4 Needing influenza immunization because of immunosuppression. The nurse and a new graduate nurse provide care for several clients. The nurse assists the new nurse with establishing client care priorities. Which client care activity does the new graduate nurse address first? 1 Instruct a client how to correctly use an incentive spirometer. . 2 . 3 Teach a client about a newly prescribed medication. . 4 Establish intravenous (IV) access for a client scheduled for surgery tomorrow. . The fire alarm sounds in the hospital that houses a locked inpatient psychiatric unit. The alarm code indicates that the fire is on another medical unit. Which priority action does the nurse on the psychiatric unit take? 1. 2. Assign a staff member to each of the unit’s locked doors. 3. Explore with clients their past experiences with fire. 4. Prepare for evacuation of the unit using the stairs. A health care provider (HCP) notifies the charge nurse of an inpatient unit that the city mayor is being admitted. The HCP states that one of the nurses on the unit is “disheveled and unkempt” and asks that the nurse be reassigned during the mayor’s hospitalization. Which response does the charge nurse provide to the HCP in this situation? 1 “I will talk to the nurse about our standards of hygiene.” . 2 . 3 “Where do you suggest this nurse work?” 4 “I have not had any complaints from any other clients.” The nurse receives hand-off communication from the previous shift about assigned clients with mental health disorders. Which client will the nurse see first? 1 Client with mania and bipolar disease threatening to sue the primary nurse for . negligence. 2 . 3 Client with delusions stating a plan to kill the spouse after being discharged. . 4 Client with schizophrenia denying hearing voices. . The home care nurse returns to the office to find four phone messages. Which message does the nurse return first? 1 . 2 A client asking when staples can be removed from an abdominal incision. 3 A client with a colostomy reporting that the skin is raw around the stoma. . 4 The spouse of a client with a cerebrovascular accident stating that the client is . refusing a bath. The nurse prepares to change the dressing on the wound of a preschool-aged client. After explaining the procedure to the client, the client begins to cry and refuses to have the dressing changed. Which response by the nurse is best? “When would you like to have the dressing changed?” 2. “I will come back later to change the dressing.” 3. 4. “It is not going to hurt at all.” The nurse educator prepares a class on crisis management. Which principle is most important for the nurse to emphasize when teaching this class? 1 The most charismatic person should assume leadership during a crisis. 2 During a crisis, leadership should be equally shared by the team members. 3 A well-prepared team does not require leadership during a crisis. 4 . The nurse delegates tasks in the emergency department. Which task does the nurse properly delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Determine whether pain medication is effective. 2. 3. 4. 5. 6. Provide discharge paperwork to a client prior to discharge. The nurse assesses a group of clients to determine the risk for developing a health care acquired infection. In which order, from greatest to least risk, should the nurse identify the risk? (Please arrange in order. All options must be used.) 86 year old client diagnosed with cancer and white blood cell count of 2,000/mm, 90 year old client with difficulty eating and is severely underweight, 52 year old client who has urinary retention and an indwelling urinary catheter in place, 62 year old client with obesity and altered sensation of the feet and lower legs. The nurse reviews the medical records for clients arriving at the community clinic for care. Which client does the nurse identify as requiring immediate intervention? 1 A client whose fourth and fifth fingers are contracted onto the palm. . 2 A client reporting numbness, tingling, and pain when the inside of the wrist is lightly . tapped. 3 A client whose fingers hurt and turn from white to blue to red in cold weather. . 4 . The nurse observes that two staff members have been in frequent conflict for the last several weeks. The nurse schedules a meeting with both staff members after observing them argue while putting a client back to bed. When meeting with the staff members, which statement by the nurse is most appropriate? 1 “One ground rule guiding this discussion is no negative comments are allowed.” 2 “One of you will speak first, and the other person will refrain from commenting until . the first person is done.” 3 “I am here to listen. My expectation is for the two of you to work this out without . intervention.” 4 . The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first? 1 Parent states the extremities of a 2-day-old newborn extend and return to the previous . position when the crib is bumped. 2 Parent states that the circumcision site of a 3-day-old newborn is covered with . yellowish exudate. 3 Parent states that a 4-day-old newborn has had one stool per day for the past 2 days. . 4 . The nurse coordinates care for clients in the emergency department (ED). Which activities can the nurse properly delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1 Determine appropriate room placement of clients. . 2 . 3 Discontinue a client’s peripheral intravenous access. 4 . 5 Determine the size of equipment needed for a client’s care. . 6 Explain to a client the reasons to return to the ED for treatment. . The nurse delivers a change-of-shift report. Which information is important for the nurse to include in the report? (Select all that apply.) 1 . 2 . 3 . 4 Description of routine morning care provided. 5 . The experienced pediatric nurse is the preceptor for a new nurse on the unit. Which action by the new nurse is appropriate? (Select all that apply.) 1 . 2 . 3 . 4 . 5 Bringing a high chair to the room of a 5-month-old to encourage the child to eat. . 6 Removing the arm board of a child whose IV is in the antecubital space, before the . child visits the playroom. Which action, if observed by the charge nurse, indicates appropriate care for a client diagnosed with increased intracranial pressure (ICP)? 1 The LPN/LVN encourages the client to cough and breathe deeply. . 2 The nurse performs nasopharangeal suctioning on the client every 2 hours. . 3 The unlicensed assistive personnel (UAP) places the client in a prone position. . 4 . The nurse provides discharge planning for a group of clients. For which client does the nurse request a health care provider's referral for home health care services? 1 A client who reports incisional pain 48 hours following an appendectomy. 2 A client diagnosed with diabetes mellitus who had a cardiac catheterization 8 hours . earlier. 3 A client who reports left knee pain 72 hours following a left total knee arthroplasty. 4 . The nurse plans care for a client who suffered a stroke 10 hours ago. The nurse receives prescriptions for several referrals. Which referral does the nurse implement first? 1. 2. Occupational therapist. 3. Home health agency. 4. Psychologist. The nurse reviews a list of clients to visit during the day. In which order will the nurse visit the clients? (Please arrange in order. All options must be used.) Client diagnosed with heart failure reporting a 3 lb weight gain in 2 days, client diagnosed with a pressure injury reporting an odor from the wound, client recently started on lisinopril reporting a dry cough, client diagnosed with chronic obstructive pulmonary disease using oxygen at 2 L per nasal cannula. The nurse receives hand-off communication from the previous shift. Which client does the nurse see first? 1 Client recovering from coronary artery bypass graft surgery who is having the . atrioventricular wires removed later in the day. 2 Client with type 1 diabetes mellitus who is scheduled for a cardiac catheterization . later today. 3 . 4 Client with cardiomyopathy who is being evaluated for a heart transplant. The nurse provides care for clients in the emergency department. The nurse assesses a client following a motor vehicle accident. Which observation most warrants the nurse remaining with this client? 1 . 2 Client’s vital signs are irregular and client is hostile. . 3 Client is agitated with a rapid respiratory rate. . 4 Client’s blood pressure is elevated and client is apprehensive. . A nurse manager notes a significant increase in inpatient client falls causing injury. To help resolve this problem, which action by the nurse manager is most appropriate? 1. Schedule a mandatory staff inservice about client safety and assessing fall risk. 2. Inform staff that evaluations and raises will reflect the unit's "zero falls" goal. 3. Convey to the staff the manager’s confidence in their abilities to provide safe care. 4. The nurse is assigned four clients at the beginning of a shift. In which order does the nurse assess the clients, beginning with the first client seen? (Please arrange in order. All options must be used.) The client experiencing chest pain, dyspnea, and hemoptysis, the client experiencing worsening dyspnea and chest pain with inspiration, the client experiencing a productive cough and an elevated temperature, the client with a chronic productive cough awaiting a biopsy. The client care team at a home care agency consists of a nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client will be assigned to the LPN/LVN? 1 Client with hypertension and hypothyroidism who is returning home from the hospital. 2 Client recovering from a kidney transplant and reporting fever and tenderness over . the transplant site. 3 . 4 Client recovering from a hip fracture and requiring assistance with a bath and hair . washing. A nursing team consists of a nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client does the nurse assign to the NAP? 1 A client diagnosed with diabetes mellitus requiring a dressing change for a stasis . ulcer. 2 A client diagnosed with terminal cancer being transferred to hospice home care. . 3 A client diagnosed with cancer of the bone reporting pain. . 4 . A client care team consists of a nurse, an LPN/LVN, and two unlicensed assistive personnel (UAP). Which client will be assigned to the nurse? 1 Client recovering from surgical repair of a hypospadias. 2 . 3 Client with a myocardial infarction (MI) who requires assistance to the bathroom. . 4 Client with urolithiasis who is recovering from lithotripsy. . A school-age client with eye inflammation tells the school nurse that the parents refuse to take the student to a health care provider for medical attention. Which action will the nurse take first? 1. 2. Notify the principal of the parents’ refusal to seek health care. 3. Notify the child protective division of the department of human resources. 4. Cleanse the drainage from the child’s eyes. The nurse plans care for a client diagnosed with left-sided paralysis and slurred speech. Which direction is most important for the nurse to provide to an unlicensed assistive personnel (UAP)? 1 Report any incontinence. 2 Turn the client every 2 hours. 3 . 4 Change the linens immediately following a bath. . The nurse oversees care activities for a client care area. Which situation will the nurse attend to first? 1 An angry adult child is threatening to sue the hospital because the confused parent . fell out of bed during the previous shift. 2 The nursing assistive personnel (NAP) is 30 minutes overdue from a dinner break in . the cafeteria for the third time this week. 3 The health care provider calls the unit to ask the nurse to obtain a client's latest . serum electrolyte results from the lab. 4 . The nurse provides care for a toddler who received ipecac syrup after accidental ingestion of a poisonous plant. It is most important for the nurse to report which information to the next shift? 1. 2. An antiemetic was prescribed and administered. 3. A slight increase in the client’s temperature is noted. 4. The client is to remain NPO until the following day. As a part of a disaster drill, the school nurse reacts to an announcement that a “dirty” bomb exploded four miles away. According to the disaster plan, which action does the nurse take first? 1 Move food and water to an interior area in the school. . 2 Contact parents to immediately pick up their children. . 3 . 4 Encourage the staff and children to remain calm. As the nurse assists an older adult client with personal care, the client states, "My son is sometimes violent." Which action by the nurse is best? 1 Discuss the information with colleagues. 2 Document the information in the medical record. 3 . 4 Share the information with the care team. . The nurse coordinates care on the medical-surgical unit. Which client indicators, if assigned by the nurse to the LPN/LVN, suggest professional negligence? (Select all that apply.) 1 Client with white blood cell count 7000/mm 3 (7 ×10 9/L). . 2 . 3 . 4 Client with prothrombin time of 10 seconds. . 5 Client with glucose 130 mg/dL (7.21 mmol/L). . 6 . While the nurse irrigates a client’s NG tube, an LPN/LVN approaches the nurse to report that a different client is hemorrhaging from the rectum. Which action by the nurse is most appropriate? 1 . 2 Manage the bleeding client and then discuss with the LPN/LVN why this was a Health . Insurance Portability and Accountability Act (HIPPA) violation. 3 Ask the LPN/LVN to obtain the client’s vital signs and immediately report them. 4 Tell the LPN/LVN to find another nurse and report about the client’s difficulties. Which action, if observed by the charge nurse, indicates appropriate care for a client diagnosed with increased intracranial pressure (ICP)? 1 The LPN/LVN encourages the client to cough and breathe deeply. 2 The nurse performs nasopharangeal suctioning on the client every 2 hours. 3 The unlicensed assistive personnel (UAP) places the client in a prone position. 4 . The nurse receives report about four pregnant clients in active labor. Which client does the nurse assess first? 1 The nullipara client with cervical dilation of 10 cm and 100% effaced. . 2 The nullipara client with fetus in transverse lie and baseline fetal heart rate of 155 . beats per minute. 3 . 4 The multipara client with fetus in a frank breech presentation and presenting part at 0 . station. A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider? 1 . 2 The client takes warfarin every day. . 3 The blood glucose level is 200 mg/dL (11.1 mmol/L). . 4 Lung sounds are diminished bilaterally at bases. . The nurse asks the unlicensed assistive personnel (UAP) to perform soapsuds enemas for a client scheduled for a diagnostic test. Which action does the nurse expect from the UAP? 1 The UAP describes the returns from the enema. . 2 . 3 The UAP asks the client to describe the returns from the enema. 4 The UAP palpates the client’s abdomen, noting firmness and tenderness. The nurse makes client care assignments for the day. Which activities can the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1 . 2 Discontinue a painful peripheral intravenous line. . 3 Verify placement of a nasogastric tube. . 4 Obtain a telephone prescription from the health care provider. . 5 Reconstitute a powdered medication with normal saline. . 6 . A nurse is promoted to charge nurse. Three months later, the staff is unhappy and feels as if their colleague has abandoned them. When interacting with the staff, which action by the charge nurse is best? 1 Try to accommodate the staff as much as possible. . 2 . 3 Resign from the position and return to the staff nurse position. 4 Explain that the charge nurse adapted to the position requirements. The nurse receives hand-off communication on assigned clients from the previous shift. Which client will the nurse assess first? 1. 2. Client with leukemia who has received 0.5 unit of packed red blood cells. 3. Client scheduled for a bronchoscopy. 4. Client complaining of a leaky colostomy bag. The psychiatric home care nurse plans visits for the day. The weather report states that the temperature will be 95 °F (35° C). Which client does the nurse see first? 1 A client with schizophrenia who is non-compliant with medications. The client lives . without air-conditioning. 2 A client with obsessive-compulsive disorder taking clomipramine. The client's . psychiatrist is vacationing. 3 . 4 A client with depression who lives alone and works in the garden. The client takes . amitriptyline for depression. The nurse provides care for a client who receives frequent opioid analgesics for pain. The client’s spouse states to the nurse, “I think my spouse is receiving too many pain medications. Next time, please administer a placebo.” Which action by the nurse is best? 1. Inform the client of the spouse’s request. 2. Administer a placebo instead of the narcotic. 3. 4. Notify the health care provider immediately. Which information is essential to report when communicating client information at the change of shift? (Select all that apply.) 1 . 2 . 3 . 4 The client has a 20-year history of smoking. 5 The client receives carvedilol, benztropine mesylate, and losartan on a daily basis Which is the first measure for the charge nurse to implement during a low-census client care shift? 1 Keep all staff to provide care for new admissions. . 2 . 3 Dismiss excess staff with instructions to stay by the phone. . 4 Dismiss excess staff and instruct them to use paid time off. . The nurse plans care for assigned clients. In which order will the nurse prioritize the care for these clients? (Please arrange in order. All options must be used.) Infant who is vomiting and has frothy oral secretions, child requiring observation following an acute asthma attack, child whose temperature has risen to 103.8 F, child diagnosed with sickle cell crisis. The nurse provides care to a client who has been comatose for 2 years. Which action will the nurse take first when entering the client’s room? 1. Elevate the head of the bed for morning tube feeding. 2. Check bony prominences for redness. 3. 4. Assess deep tendon reflexes. The nurse in the outpatient clinic receives a phone call from a young adult client who says a friend has overdosed. In caring for the overdosed client, which action does the nurse take first? 1 Instruct the friend to call emergency medical services. . 2 Instruct the friend to call the Poison Control Center. . 3 Find out what the client ingested and in what amount. . 4 . The nurse assesses the pain level of clients recovering from surgery. Which clients’ pain relief are appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.) 1 . 2 Client who arrived from the post-anesthesia care unit a short while ago after an . appendectomy, is dozing intermittently, and reports pain as 8 out of 10. 3 . 4 Client who had surgery to repair a hip fracture yesterday evening and is difficult to . arouse, yet moans when moved. 5 Client on NPO status after a colon resection 4 days ago who reports pain as 7 out of . 10. 6 . As the nurse administers medications to a group of clients, an unlicensed assistive personnel (UAP) approaches the nurse to report that a client has a large amount of thick, dry mucus on one side of the tracheostomy tube. Which response does the nurse provide the UAP in this situation? 1 “Please take these medications into the medication room for me. ” 2 . 3 “Take a sterile cotton swab and remove the mucus, please. ” . 4 “Please find another nurse to take care of the client. ” . The nurse receives hand-off communication from the previous shift. Which client will the nurse see first? 1 Client receiving a blood transfusion who reports a dry mouth. . 2 Client scheduled to receive heparin who has an aPTT of 70 seconds. . 3 . 4 Client receiving an intravenous potassium infusion who reports burning at the catheter . site. The nurse assigns a client prescribed a continuous bladder irrigation to an unlicensed assistive personnel (UAP). Which tasks can be delegated to the UAP? (Select all that apply.) 1 Assess patency of the three-way urinary catheter. . 2 Manually irrigate the catheter if daily gau is decreased. . 3 . 4 . 5 . The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? (Select all that apply.) 1 A client following throat surgery for cancer with a history of diabetes. . 2 . 3 . 4 A client diagnosed with hydrocephalus after a ventricular peritoneal shunt . placement. 5 . A client care team consists of a nurse, an LPN/LVN and a nursing assistive personnel (NAP). Which client will be assigned to the nurse? 1 . 2 Client recovering from an ectopic pregnancy. . 3 Client recovering from the removal of a hydatidiform mole. . 4 Client recovering from a vaginal hysterectomy. . The charge nurse implements a change in the nursing assistive personnel’s (NAP's) job description. A nurse on the unit verbally agrees to the change, but behavior indicates that the nurse does not agree with the new job description. Which action made by the charge nurse is most appropriate? 1 Tell the nurse that the witnessed behavior is unacceptable. . 2 Schedule an appointment with the nurse. . 3 Ask the NAPs to accommodate the nurse. . 4 . The nurse provides care for clients on an acute pulmonary unit. The nurse prepares a written report for the next shift. Which information is most critical to communicate to the next shift? 1 Abnormal laboratory work, arterial blood gas reports, nutritional intake, and vital signs . for the shift. 2 . 3 Name of each client ’s health care provider, the date each client was admitted, dietary . intake for each client, and each client's general condition. 4 Urinary output, fluid intake, visits by the attending health care provider, vital signs, . and any respiratory problems encountered. The new graduate nurse is asked by the preceptor why the time spent with the client was longer than expected. The new graduate replies, "I taught the client how to use the incentive spirometer. The client did not understand that you have to inhale and hold your breath." The preceptor responds, "It’s not inhale with an incentive spirometer, it’s exhale." Which action does the new graduate nurse take? 1 Return to the client and explain that they should hold their breath on exhalation, not . inhalation. 2 . 3 Explain that it was stressed in class that inhalation, not exhalation, was appropriate . for the incentive spirometer. 4 Tell the preceptor that this erroneous information is shocking and the matter needs go . to the manager. The nurse supervises the care provided by a nursing assistive personnel (NAP) to a client being treated with a radioactive implant for vaginal cancer. Which situation requires the nurse to intervene? 1 The NAP spends a half hour in the client’s room helping with morning care. 2 The NAP places all the equipment needed for morning care on the bedside table. 3 . 4 The NAP stands 6 feet away when talking with the client. . A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour? 1 A postpartum client who delivered 4 hours ago and has an intact perineum. 2 A postpartum client diagnosed with an infection who has been receiving antibiotics for . the past 24 hours. 3 A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting. 4 . The charge nurse on a cardiac care unit makes assignments. Which client is appropriate to assign to a float nurse from the medical-surgical unit? (Select all that apply.) 1. A client with an intravenous infusion of epinephrine for heart failure. 2. 3. 4. 5. A client newly admitted with kidney failure secondary to heart failure. A client in a same-sex marriage is scheduled for abdominal surgery. During surgery, the client’s spouse requests information regarding the client’s status. Which response by the nurse is appropriate? 1 “The health care provider will be out to talk with you after the surgery is complete.” 2 “I am sorry. I can only give out information to family members.” 3 . 4 “I am sure things are going fine, so just sit back and relax.” . The nurse supervises a team of LPN/LVNs. Which client care tasks can be completed by an LPN/LVN? (Select all that apply.) 1 . 2 Care for a client who has a total serum calcium level of 11.4 mg/dL (2.85 mmol/L). 3 . 4 Care for a client who has arm tingling after diving in pool and striking the face. . 5 Develop a plan of care for a client admitted with pyelonephritis. . 6 . The nurse at the daycare center observes children playing on the playground. Which observation requires immediate intervention by the nurse? 1 Two children fighting over a ball. 2 One child trying to pull another child off a swing. 3 A toddler who is crying, tugging at the ear, and hugging a stuffed animal. 4 . The nurse reviews a list of clients waiting to be seen in the emergency department (ED). Which clients will the nurse select to be seen immediately? (Select all that apply.) 1. 2. 3. Experiencing redness on the lower legs for the past week. 4. 5. Demonstrating drowsiness after taking cyclobenzaprine. 6. Which clients are appropriate for the charge nurse to assign to the LPN/LVN on a medical unit? (Select all that apply.) 1 . 2 The client with a serum potassium level of 2.8 mEq/L (2.8 mmol/L). 3 . 4 . 5 The client with moderate low back pain who is restless. 6 . The nurse manager is informed that a client on the unit has developed a central line- associated bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an investigation of the incident. Which actions are appropriate for the nurse to take in this situation? (Select all that apply.) 1 . 2 . 3 . 4 Reassure the client and family that the CLABSI was unavoidable. 5 Instruct the nurses who cared for the client to obtain legal counsel. A 21-year-old college student diagnosed with asthma falls on the running track while preparing for a track meet. Use of the inhaler restores breathing and equilibrium. The student is conscious, alert, and oriented. Blood pressure is 120/82 mm Hg, pulse is 84 beats/min, and respirations are 14 breaths/min. The university health center nurse asks the student to go to the emergency department to obtain medical evaluation. The student refuses to seek medical evaluation. Which action is most appropriate for the nurse to take? 1 Contact the student ’s parents to obtain consent for hospital evaluation and any . needed treatment. 2 Call an ambulance and ask the student for an emergency contact name. . 3 . 4 Suggest the coach remove the student from the training roster unless the student . consents to be medically evaluated. The nurse is making client assignments on a medical/surgical unit. The staff includes one nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client does the nurse assign to the LPN/LVN? 1 A client who had a detached retina surgically repaired 4 hours ago. . 2 A client who requires toileting assistance after receiving bowel prep for abdominal . surgery. 3 . 4 A client who is 1 day postoperative after a laminectomy with spinal fusion. The long-term care nurse admits a client transferred from the hospital. Which statement accurately describes a transition concept among older adults? 1. Immediate psychological improvement will be noted. 2. 3. There are fewer medication errors in long-term care settings. 4. Short-term antianxiety medication is helpful in the first week. The nurse provides care for clients on the medical and surgical unit. Which situation requires immediate intervention by the nurse? 1 . 2 A visitor is sitting without a mask just inside the doorway of a client on droplet . precautions. 3 A client who had a cholecystectomy 2 days ago is draining purulent fluid through the . T-tube. 4 A client scheduled for a cardiac catheterization is expressing anxiety and reservations . about undergoing the procedure. The nurse assigns a client who is receiving oxygen via a Venturi mask to the nursing assistive personnel (NAP). Which tasks can be delegated by the nurse to the NAP? (Select all that apply.) 1 . 2 . 3 . 4 . 5 Adjust the oxygen flow rate based on the client’s need. . The nurse oversees care provided by an LPN/LVN and the nursing assistive personnel (NAP). Which task is most appropriate to delegate to the NAP? 1 Monitor a client during the first 15 minutes after the nurse begins a blood transfusion. . 2 Determine the patency of a chest tube drainage system for a client with a . pneumothorax. 3 Teach a client newly diagnosed with type 1 diabetes mellitus how to fill out the menu. . 4 . The nurse leads an in-service on the ethical principle of beneficence and discusses the recent case of a client just diagnosed with breast cancer. Which is the best action for the nurse to take? 1 Make a treatment decision for the client. . 2 Tell the client that the breast tumor is non-malignant. . 3 Explain to the client about the right to privacy at this time. . 4 . The charge nurse assists a new nurse in learning client care management and delegation. The charge nurse counsels the new nurse when which actions are observed? (Select all that apply.) 1 The new nurse asks the charge nurse to assist with the insertion of an IV catheter . after two failed attempts. 2 . 3 The new nurse asks the unlicensed assistive personnel (UAP) to perform a complete . bed bath on a bedbound client with a tracheostomy. 4 . 5 . The nurse receives report from the previous shift on four clients. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.) A client with a clammy hematoma who has a sudden onset of acute confusion, a client requesting pain medication for postsurgical pain rated 7 on a 0 to 10 scale, a client who has a new prescription to insert a nasogastric tube with low intermittent suction, a client with Alzheimer disease who is disoriented to place, time, and event. The nurse assigns the LPN/LVN to perform a moist-to-dry dressing change on the client's 2- inch incision. Which behavior, if performed by the LPN/LVN, requires an intervention by the nurse? 1 . 2 Dry dressings are placed over the saline-moistened gauze in the incision. . 3 Wound debris and necrotic tissue are removed with the old dressing. . 4 The gauze is moistened with sterile saline before it is packed into the incision. . The nurse provides care for clients in the emergency department. Which client does the nurse assess first? 1. A client with a burn to the palm of the hand. 2. 3. A client reporting blood and blood clots in the urine. 4. A client reporting right lower leg pain, edema, and warmth. The nurse oversees care provided by the LPN/LVN, and the nursing assistive personnel (NAP). Which client will the nurse assign to the NAP? 1 Client with a 5-day-old ostomy requiring stoma care and application of an ostomy . appliance. 2 Client in a coma after experiencing a head injury requiring cranial nerve assessment . and Glasgow coma scale evaluation. 3 Client with a spinal cord injury requiring range-of-motion exercises and instruction . about autonomic dysreflexia. 4 . The nurse reviews prescriptions for a newly admitted client. Which prescriptions does the nurse clarify with the health care provider? ( Select all that apply.) 1. 2. Docusate 100 mg PO twice daily. 3. 4. 5. Tetracycline 250 mg PO four times daily. An older adult client diagnosed with type 1 diabetes mellitus (DM) relocates to a nursing facility, but neglects to bring all prescribed medication. Which response is the best for the nurse to make when the client says the missing medication relieves burning and stinging in the feet and legs? 1 . 2 “Can you describe the signs and symptoms to me?” . 3 “Can you describe what the medication looks like?” . 4 “Did the health care provider tell you what caused the burning and stinging?” . The unlicensed assistive personnel (UAP) ambulates a client to the bathroom. The nurse overhears the UAP ask a family member to stand with the client while the UAP cares for another client. Which response by the nurse to the UAP is best? 1 “Why did you ask the family member to stay with the client?” 2 . 3 “Do not ask a family member to do your job.” . 4 “Did the client ask you to leave?” . A graduate nurse expresses difficulty with time management when providing client care. Which is the best response from the graduate nurse's preceptor? 1. "I have some ideas to help you better manage your time." 2. "How much practice did you get in school taking care of groups of clients?" 3. 4. "Tell me how you feel about time in general." A nurse with postpartum care experience is reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse? 1 Client with facial trauma after a motor vehicle crash. 2 Client with heat stroke. . 3 Client having a systemic reaction to latex. 4 . The nurse manager reviews the medical records for clients receiving care on the unit. Which documentation entries require the completion of an incident report? (Select all that apply.) 1 . 2 “Client reports 8/10 pain after receiving pain medication. Health care provider . notified.” 3 . 4 . 5 . The nursing student asks the nurse, “What are Good Samaritan laws?” Which response by the nurse is accurate? 1 “Good Samaritan laws require health care facilities to provide material to clients about . rights.” 2 “Good Samaritan laws provide clients with the right to be free from chemical . restraints.” 3 . 4 “Good Samaritan laws require the reporting of threatened suicide or harm to others.” . The nurse makes client assignments after making rounds. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client immediately postop for an abdominal hysterectomy experiencing nausea. 2. A client with a spinal cord injury at the level of C6 reporting a pounding headache. 3. A client diagnosed with an abdominal wound that requires a sterile dressing change. 4. The nurse providing care for clients with diabetes mellitus receives report. Which client does the nurse see first? 1 A female client who reports urinary frequency and burning with urination. 2 . 3 A client with a BP of 120/50 mm Hg who reports frequent urination and thirst. 4 A client who reports experiencing constant hunger. The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse? 1 The health care provider prepares to insert the needle for a lumbar puncture at the . level of the posterior iliac crest. 2 As the nurse leaves the client ’s room, the nurse removes gloves and then the gown, . folding the gown inside out. 3 The unlicensed assistive personnel (UAP) feeds a client while the client ’s neck and . head are flexed slightly forward. 4 . During the administration of IV digoxin to a client, the nurse is informed by the unit secretary that an assigned client with extensive head and facial injuries has arrived on the unit. Which action does the nurse take? 1 Place the syringe with the remaining medication on the medication cart. 2 Instruct the unit secretary to find another nurse to admit the client. 3 . 4 Request that the LPN/LVN complete the administration of the medication. . The nurse supervises care on the medical-surgical unit. Which situation does the nurse attend to first? 1 The unlicensed assistive personnel (UAP) enters the room of the client diagnosed with . Pneumocystis jiroveci pneumonia wearing gown, N95 mask, and gloves. 2 . 3 The family of a client reports that the toilet in the client's bathroom is overflowing. 4 A client diagnosed with tuberculosis is ready for discharge and waiting for discharge . instructions. The nurse provides care for school age clients at summer camp. Which client in the infirmary does the camp nurse assess first? 1 A child with hemophilia reporting a headache and experiencing slurred speech. 2 A child with type 1 diabetes who is nervous, pale, and diaphoretic. 3 A child with asthma reporting a sore throat and demonstrating restlessness. . 4 . The nurse manager prepares to implement self-scheduling for the unit. In which order does the nurse manager proceed with this task? (Please arrange in order. All options must be used.) Assess unit staffing needs, discuss unit staffing needs with supervisor, hold a unit meeting to educate staff about self-scheduling, post a blank schedule on the unit for staff to choose their shifts, review the schedule and revise as needed. The charge nurse meets with the nurse manager and provides a document providing extensive rationales about why the staff has voted not to implement the new care delivery model as instructed. Which action by the nurse manager is most appropriate? 1 . 2 Reprimand the charge nurse in writing for insubordination and place in employee file. 3 Instruct the nurse to inform the staff that the delivery model will be implemented. 4 Meet with the staff to obtain feedback regarding their concerns about the delivery . model. The nurse on the long-term care unit identifies a higher than expected incidence of impaired skin integrity among the clients. The nurse calls a staff meeting to obtain input about the problem. Which suggestion indicates that the staff member feels empowered to solve the problem? 1 . 2 A practical nurse states that incontinence during the night is the main factor and . suggests that fluids be restricted after the evening meal. 3 A practical nurse states that shearing force is a factor and suggests that the nursing . assistive personnel be more gentle when repositioning clients. 4 The registered nurse states that clients are left sitting for too long and announces that . from now on clients will be repositioned every hour. The nurse provides care for clients in the diabetic clinic. Which client does the nurse assess first? 1 . 2 The client reporting pain in both calves when exercising. 3 The client drinking copious water with constant hunger. 4 The client with difficulty sleeping and frequent crying. . The nurse receives report on four clients. Which client does the nurse see first? 1 The client who has a deep vein thrombosis (DVT) and an international normalized . ratio (INR) level of 9. 2 . 3 The client reporting lower abdominal pain and nausea with a positive Rovsing sign. . 4 The client reporting a foul-smelling leg ulcer and who has a history of diabetes . mellitus. The nurse notes that four clients arrive for emergency care at the same time. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.) Client diagnosed with dyspnea and swollen lips after being stung by a bee, client diagnosed with diaphoresis and feeling chest pressure, client diagnosed with an open fracture and chest contusions from a motor vehicle crash, client diagnosed with COPD experiencing shortness of breath and an oxygen saturation of 88 percent. A nursing assistive personnel (NAP) reports to the nurse that a comatose client receiving oxygen through a tracheostomy has “lots of water in the tubing.” Which action does the nurse take? 1 Ask the NAP to clarify “lots of water.” 2 Instruct the NAP to empty the fluid. 3 Contact respiratory therapy to evaluate the tubing. 4 . The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which elements required to be present in a malpractice case? (Select all that apply.) 1. Intention. 2. 3. 4. 5. The nurse manager wants to increase the number of nurses on the unit. This will require nurses to serve as new preceptors. Which action does the nurse manager take? (Select all that apply.) 1 . 2 . 3 . 4 Require all unit nurses to attend preceptor training within one year of hire. . 5 Meet individually with all unit nurses to explain the benefits of being a preceptor. . 6 Allow preceptors to determine how long they will work with the newly hired nurse. . The nurse receives hand-off communication from the previous shift. Which client will the nurse see first? 1 Client with chronic renal failure reporting swollen fingers and ankle edema. . 2 Client 1 day postoperative after abdominal surgery with dried blood on the abdominal . dressing. 3 . 4 Client on high doses of antibiotics for a resistant infection reporting diarrhea. At 2100, the nurse notes that the last client documentation was at 0900. The nurse on the previous shift did not complete or sign the documentation for that period of care. Which action by the nurse is correct? 1 . 2 Leave enough space for the previous nurse to complete documentation when the . nurse returns. 3 Withhold documentation until the previous nurse returns to complete documenting for . care delivered. 4 Contact the nurse from the previous shift, obtain a verbal report, and complete the . documentation. The home health care nurse visits a client diagnosed with progressive systemic sclerosis. The client reports more trouble swallowing and moving the right hand. Which suggestion does the nurse make first? 1 . 2 “Participate in a support group. ” . 3 “Wear a glove on the right hand. ” . 4 “Wait 1 hour after eating to lie down. ” . The nurse understands that debates over client's abortion rights are often based on conflict between which pairs of ethical principles? 1 Beneficence and justice. . 2 Veracity and fidelity. . 3 . 4 Paternalism and restitution. The nurse works on a new care area, created through the merging of two separate areas. The staff from the original care areas differ on client care approaches, which creates conflict between the two groups despite having meetings together to try to improve collaboration. Which suggestion is the most appropriate for the nurse to make to the charge nurse to reduce the amount of conflict between the two groups of staff? 1 . 2 Hold an in-service about the benefits of merging the two units. 3 Institute disciplinary action for staff members who talk negatively. 4 Require all staff to listen to hand-off communication on all of the clients. The hospital nurse educator plans an inservice for staff on the topic of working with interpreters. Which statement is appropriate for the nurse to include? 1 "Look directly at the interpreter while you are asking the questions." 2 . 3 "Interrupt the client and interpreter if they seem to be talking longer than the question . requires." 4 "Focus primarily on the client’s body language and tone of voice." . The nurse receives report on the client who had an extensive stroke and is aphasic with a do not resuscitate (DNR) prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally, and O 2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which actions will the nurse implement based on these data? (Select all that apply.) 1 . 2 . 3 . 4 . 5 . 6 Place the client in high-Fowler's position. The nurse plans home care visits for the day. Which client will the nurse see first? 1 Older adult client discharged yesterday following treatment with intravenous heparin . for a deep vein thrombosis. 2 Older adult client being regulated on warfarin. . 3 Older adult client discharged from the hospital 3 days ago with pneumonia. . 4 . The nurse overhears the nursing assistive personnel (NAP) discuss a client who is hospitalized under an alias after being injured while committing a crime. Which statement will the nurse make to the NAP? (Select all that apply.) 1 "As long as we don't talk to anyone else, it's fine to gossip among ourselves." . 2 . 3 . 4 "I will tell you what crime was committed after I ask the client." . 5 . The nurse provides care for several clients. Which client does the nurse assess first? 1 . 2 An older adult male client reporting abdominal pain, vomiting, and diarrhea. 3 A middle-age female adult client reporting productive cough and shortness of breath. 4 An older adult male client reporting urinary hesitancy and weak urinary stream. . The nurse develops a brochure about informed consent. Which statements are appropriate for the nurse to include in the brochure? (Select all that apply.) 1 . 2 . 3 . 4 Obtaining a client’s informed consent is a nurse’s responsibility. . 5 Mentally ill clients do not retain the right to refuse treatment. . A client in a semiprivate room with a roommate is visited by an employee from the hospital business office. The employee discusses the client's inability to pay for services. The client then reports to the nurse that a right to privacy was violated. Which action does the nurse take first? 1 . 2 Tell the client that his roommate was probably not listening. 3 Inform the client that the business office had to straighten out the client's account. 4 Contact the business office so the client can talk with the employee. The nursing team consists of a nurse, a LPN/LVN, and two nursing assistive personnel (NAPs). Which client does the nurse assign to the LPN/LVN? 1 A client 2 days postoperative after abdominal hysterectomy asking to ambulate in the . hall. 2 . 3 A client with a right-sided cerebrovascular accident (CVA) requiring assistance with . bathing. 4 A client refusing medication for treatment of cancer of the colon. . The nurse receives hand-off communication from the nurse who provided care to a group of clients during the previous shift. Which client does the nurse see first? 1 A client with dementia who is at risk for falling. . 2 A client with an intravenous (IV) infusion 1 day post-operative. . 3 . 4 A client with a hip fracture reporting 9/10 on a pain scale. The client states to the nurs