WorksheetsNursing Management and Clinical Decision-Making Worksheet
Total questions: 95
Worksheet time: 49mins
The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority).
Oxygen 2 liters nasal cannula
Blood and sputum cultures
IV normal saline at 100 mL/hr
Ceftriaxone (Rocephin) 1 gram every 12 hours
Finger stick before each meal and at bedtime
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM?
All employees participate in systematically working toward common goals
It is a reactionary approach used to investigate the root cause of a problem
Top administrators are responsible for establishing plans for problem management
It is an incident management technique that focuses on employee retention
The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation?
Stay neutral and allow the staff nurse to handle this situation independently
Request an immediate private meeting with the health care provider and staff nurse
Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
Notify the chief nursing officer about the breach of professional conduct
All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first?
62-year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8
79-year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10
70-year-old following surgical repair of a femur fracture, no bowel movement since before surgery
67-year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing
The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the ED?
Notify the nursing supervisor and request additional staff
Prepare the trauma room and select supplies
Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank
Activate the disaster plan
The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse?
The client's self-report of pain is the most important consideration
Nurses should not prejudge a client's pain using their own values
Clients have the right to have their pain relieved
Cultural sensitivity is fundamental to pain management
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects assertive communication?
I am having difficulty reading your handwriting. It would save me time if you would be more careful.
Please print in the future so I do not have to spend extra time attempting to read your writing.
Would you please clarify what you have written so I am sure I am reading it correctly?
I cannot give this medication as it is written. I have no idea of what you mean.
A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice?
A female interpreter who does not know the client
A female neighbor of the client who is also from Bosnia
The client's adult daughter
A Bosnian male, who is a certified medical interpreter
A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate?
Ignore the woman and continue with tasks
Ask the woman to identify herself and state her purpose for being at the nurses station
Report the woman to security
Allow the woman to continue looking at the charts
The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next?
Administer the medication as ordered
Ask another staff nurse to discuss the same concerns with the hospitalist
Request a consult with the in-house pharmacist
Page the attending physician to express the same concerns
A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse?
Assign the graduated staff nurse to be transferred to another floor for the shift
Provide an immediate one-on-one, personal in-service about the drain
Check with the nurse and the client often during the shift
Change the assignment; reassign the client with the lumbar drain to a different nurse
The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment?
Which clients should I see as I begin my day?
Which groups are at the greatest risk for problems?
Which physicians will I be more closely collaborating with?
Which nursing assistants can I refer clients to?
The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?
Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."
State strongly: "Stop. Tell me why there's no urine in the tubing."
In a speaking tone of voice, explain: "The tubing is probably in the vagina."
Ask the student in a calm voice: "Did you do something wrong?"
The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients?
An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation
An elderly person who was admitted three hours ago with a diagnosis of cyclothymia
A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder
A young adult who was admitted 24 hours ago for treatment following detoxification
A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement?
The client has a right to know about the use and side effects of the prescribed medications
Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects
A referral is needed to the psychiatrist who should provide the client with answers to the request
The charge nurse is assigning duties to the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)?
Provide stoma care for a client with a well-functioning ostomy
Care for a recent complicated double barrel colostomy
Assess the function of a newly created ileostomy
Teach the initial ostomy care to a client and family members
The charge nurse reviews nursing roles and functions with a newly-hired licensed practical nurse (LPN). The LPN asks for more information about the role of the Minimum Data Set (MDS) coordinator. Which statement best explains the role of the MDS coordinator?
The MDS coordinator is responsible for assessing and documenting the clinical status of residents in long-term care facilities.
The MDS coordinator manages the financial accounts of the nursing facility.
The MDS coordinator provides direct bedside care to all residents.
The MDS coordinator supervises dietary services in the facility.
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse?
Report of unstable angina with continuous telemetry monitoring
Tracheostomy of 24 hours with the client showing some respiratory distress
Pacemaker insertion on the day shift
Dopamine IV drip with vital signs monitored every five minutes
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults?
Family preferences
Reconciliation of medications
Poor communication among providers
Excellent primary care
Client health status
The MDS coordinator, who is a full time registered nurse, completes the minimum data set (MDS) for a new admission to a skilled nursing facility. Why does the nurse complete the MDS?
It provides a standardized set of essential clinical and functional status measures
It will be used to measure outcomes of nursing care
It is required for all clients in a Medicare- or Medicaid-certified nursing facility
It's used to direct the care that may be performed by nursing assistants
It is required by the board of nurses
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement?
Ignore him and get the rest of your work done. Someone else can care for him the rest of the day.
He has a lot of problems. You need to have patience with him.
He may be scared and taking it out on you. Let's talk to figure out what to do next.
I will talk with him and try to figure out what to do or what the problem is.
A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these approaches?
Inform the client that the hospital policy prohibits staff to date clients
Discuss the boundaries of a therapeutic relationship with the client
Tell the client that such behavior is inappropriate and unethical
Ask not to be assigned to this client or request to work on another unit
The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take?
Make a clinic appointment with the primary health provider for follow-up care the next day
Teach a family member clean dressing change technique and address safety measures in the home
Collaborate with the health care provider about the change of condition
Collaborate with the dietitian for increasing protein and calcium in the diet
The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee?
What degree of supervision for basic care do you think you need?
What types of complex client-care tasks or assignments do you prefer?
Let's review your skills checklist for type and level of skill for tasks.
Let's talk about your comfort zone for working independently.
The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first?
A 20 year-old in skeletal traction for two weeks since a motorcycle accident
A 72 year-old who returned from a right hip replacement surgery two hours ago
A 16 year-old who had an open reduction of a fractured wrist 10 hours ago
A 75 year-old who is in skin traction of the left leg prior to a scheduled fractured hip repair surgery
The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law?
Complete and accurate documentation of assessments and interventions
Clinical specialty certification by an accredited organization
Above-average performance reviews prepared by nurse manager
Sworn statement that health care provider orders were followed
The triage nurse identifies that a 16 year-old client is legally married and has signed the consent form for treatment. What should be an appropriate action by the nurse?
Ask the teenager to wait until a parent or legal guardian can be contacted
Withhold treatment until telephone consent can be obtained from the partner
Refer the teenager to a community pediatric hospital emergency department
Proceed with the triage process in the same manner as any adult client
The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real nor name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online?
The nurse would be reprimanded for not receiving written consent from the client prior to posting
The nurse could be fired for breach of confidentiality
There won't be any consequences because the information was posted on a website for nursing professionals
There won't be any consequences because the client's real name was not used
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate?
Encourage the client to discuss this decision with the health care provider and family
Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time
Tell the family members that the client's preference is to go home to die
No action is needed at this time unless the client repeats the statement to another caregiver
A client who is unconscious is brought to the emergency department by an ambulance. What document should be given priority to guide the approach for the care of this client?
The national statement of client rights and the client self-determination act
The clinical pathway protocol of the agency and the emergency department
Orders written by the health care provider in the emergency department
A notarized original of the advance directive brought in by the partner
The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program?
Reduce readmissions to the hospital
Increase satisfaction with nursing care
A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first?
Viral pneumonia with atelectasis
Tension pneumothorax with slight tracheal deviation to the right
Acute asthma with episodes of bronchospasm
Spontaneous pneumothorax with a respiratory rate of 38
A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?
Confront the nurse about the suspicions in a private meeting
Schedule a staff conference, without the nurse present, to collect information
Consult with human resources personnel about the issue and needed actions
Counsel the employee to resign to avoid investigation and rumors
The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model?
An appointed board oversees any administrative decisions
Non-nurse managers supervise nursing staff in groups of units
Nursing departments share responsibility for client outcomes
Staff groups are appointed to discuss nursing practice and client education issues
Two new graduates are working in a busy emergency department (ED). With limited experience, the nurses may need to consult experts to assist them with client care. Which management decision impedes access to needed information?
Scheduling both experienced and less experienced staff on the same shift
Assigning preceptors to new grads
Instituting an internship for nurses beginning employment in the ED
Blocking access to the internet on all ED computers
The nurse is working in a small hospital in a rural town. A nurse from the ED calls the floor to ask about a client who was admitted from her neighborhood. The nurse answering the phone is worried that she will offend the ED nurse. What should the nurse do?
Answer the question for the nurse as she is employed by the hospital
Refrain from answering the question, as the nurse is not in a position to "need to know."
Tell the nurse that the client is no longer in the hospital
Give the nurse the client's family phone number
The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse for her password so that he can get the information. What should the nurse do?
Enter the personal password and allow the volunteer to retrieve the information
Tell the volunteer that only staff have access
Tell the volunteer the password and allow him to retrieve the information
Obtain the information at the end of the shift
The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action?
The client has the right to a safe care environment
The nurse may be sued for malpractice if injury occurs
All clients on mental health units are placed on suicide precautions
Clients are most likely to act on suicidal thoughts when energy is low
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult?
Six year old who had surgery 5 days ago, receiving liquid diet since surgery
Twelve year old admitted 5 days ago receiving TPN
Two year old taking only liquids since admission 24 hours ago
Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula
Which nurse is providing cost effective care to a client?
Providing palliative care to a terminally ill client.
Beginning discharge planning on admit.
Counseling clients on cigarette smoking cessation.
Educating a group of parents on the importance of childhood immunizations.
Performing a postop wound dressing change using clean gloves.
The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by his employer and his spouse. What is the best rationale for including assertiveness training in this client's treatment plan?
All clients should have assertiveness skills.
The client has low self-esteem.
The client is being taught self-advocacy.
No client deserves to be manipulated by an employer.
The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate?
Life-threatening complications for the client.
Legal action against the nurse and/or healthcare facility.
Suspension of license or loss of license to practice nursing.
Suspension of license or loss of license to practice medicine.
Loss of client autonomy and right to make decisions.
A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do?
Inform the primary healthcare provider that the client is wishes to leave.
Make arrangements for a commitment hearing.
Tell the client the primary healthcare provider must discharge the client prior to leaving.
Call the client's family to come and request a discharge order.
An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority?
Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid.
Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds.
A client who "passed out" but regained consciousness when his feet were elevated. Awake and confused, with warm and dry skin.
An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply:
Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services.
Appears to be having abdominal discomfort.
Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.
Pre op Diazepam 10.0 mg given po.
Transferred to surgical suite per stretcher with side rails up, in stable condition.
A client with cancer refuses treatment and asks about options for hospice home care. The clients' daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right?
Self-determination
Ability to decline participation in research studies and experimental treatments
To expect reasonable continuity of care
To make decisions about the plan of care
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? Select all that apply:
Plate guards
Transfer belt
Raised toilet seat
Long handled shoe horn
Wide grip utensils
After shift report, which client should the nurse see first?
Eight year old that is in skeletal traction.
Six year old that had an appendectomy 6 hours ago.
Unattended two year old admitted for a sleep study.
Four year old cerebral palsy child with a tracheostomy admitted for UTI.
A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply:
Place colorful posters regarding infection control in conspicuous places on unit.
Monitor staff providing client care for the use of appropriate infection control.
Give staff a written test on proper infection control.
Have all staff read agency policy and procedures regarding infection control.
Provide mandatory in-service sessions on infection control for every shift.
The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restrictive to most restrictive?
Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room.
Place client in the isolation room with staff observation.
Walk the client out to the courtyard.
Take the client to the client's room for a time out.
Restrain client's arms with wrist restraints.
A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the RN delegate to an unlicensed assistive personnel (UAP)?
Reminding the client to apply the CPAP at bedtime
Obtaining oxygen saturation levels every three hours
Teaching the client how to turn on the CPAP machine
Assessing for fatigue or depression caused by poor sleep
A rape victim is admitted to the emergency department for care. The police and primary healthcare provider insist that the client consent to a rape kit examination, but the client refuses. What should the nurse do?
Assist in the rape examination since this is a legal matter.
Isolate the client so she can think about her decision.
Respect the client's wishes.
Notify the closest relative who will influence the client to have exam.
The unit nurse manager would like to change the way shift report is conducted on the unit. Which activity would be most beneficial in creating this change?
Assign several research articles on the "art of shift report" as reading for the staff to complete and discuss.
Have the staff float to other units in order to observe the various ways the institution performs shift report.
Introduce the idea at a staff meeting and gather input on possible methods with pros and cons; then implement a change.
Announce the change to all the staff and the implementation date of the planned change.
Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
Clinical nutritionist
Primary nurse each shift
Primary healthcare provider
Case manager
Which sign/symptom of hypoxemia in a client with pneumonia is most important for the nurse to report to the primary healthcare provider?
Radial pulse of 98
Arterial blood gas PaO2 of 96
Fatigue
Confusion
The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?
Report the incident to the nursing supervisor.
Write up a variance report about the incidence.
Instruct the students that this is a violation of HIPPA.
Notify the students' faculty regarding the violation
Which client must the nurse assign to a private room?
Primiparous client who delivered twins at 28 weeks gestation two days ago
Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis
Postpartum client whose 2 hour old infant is being worked up for sepsis
Postpartum client 32 hours after delivery with a temperature of 101° F (38.05° C)
A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager?
Meet with the family member and the RN to discuss the disagreement regarding the dressing change.
Assure the family member that the nurse followed the hospital procedure.
Discuss the dressing change procedure with the RN and compare to a current textbook.
Report the argument to the hospital administrator.
The nurse is working with a client in the home environment. The major issue of concern for the client is the prognosis for the cancer that was diagnosed three months ago. When the nurse visits, the client asks, "How do I know if what I am reading on the World Wide Web is true and correct about cancer treatment?" Which response by the nurse indicates understanding of the evaluation process for web based medical information?
Most information about medical problems is up to date.
Look for credible websites such as .gov, .edu, and .org.
If there are ads on the page, the site is probably not a credible one.
Look for easy navigation of the site.
The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min; blood pressure 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138/min. What action should the nurse take first?
Turn off alarm, then check ventilator settings.
Increase FiO2 setting to 100%.
Hyperventilate client, then suction ET tube.
Auscultate lung sounds.
An experienced RN and LPN are working with a new graduate nurse. The graduate has just recently passed NCLEX. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor may act as a barrier to delegation?
Lack of experience of the new graduate.
The level of education of the staff.
Lack of comfort with conflict.
Worry about being perceived as lazy.
A national emergency situation exists in a small coastal town where there have been massive flooding and casualties. The damaged hospital is still receiving victims for treatment. Several nurses have volunteered to triage victims during this time. Family members have been asking about the status of loved ones who may have possibly been to the hospital. What action should the nurses take?
Tell the family members that they cannot give any personal information about clients.
Ask for the victims' permission before talking with the family members.
Instruct the family to wait for public announcements about victims.
Give information to the family.
The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first?
Share the assessment findings with the interdisciplinary team.
Suggest that the social worker visit the client in the home.
A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure?
Use an audiotape made in Spanish to inform the client of the pre-surgical procedure.
Draw pictures of what to the client can expect prior to surgery.
Facial expressions and gestures can be used to let the client know what to expect.
Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.
The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do?
Tell the client that the behavior is inappropriate.
Accompany the client to the TV room on the unit.
Allow the male client to handle the situation.
Continue with the unit routine.
A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision?
The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments.
The charge nurses do that to everyone. It can be annoying sometimes, I know.
Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention.
You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.
Which client could the charge nurse reassign to an LPN/VN?
Eight year old in diabetic ketoacidosis
Six year old in sickle cell crisis
Two month old with dehydration
Five year old in skeletal traction
Which room assignment would be most therapeutic for the nurse to make for a manic client who is hyperactive and has difficulty sleeping?
A private bedroom.
A semi private room with a roommate who has a similar problem.
Either a private or a semi private room.
Direct admission to the seclusion room until his activity level becomes more subdued.
Which goal is the most important for a nurse to address for a client admitted to the cardiac rehabilitation unit?
Reduction of anxiety
Referral to community resources
Identification of lifestyle changes
Verbalization of energy-conservation techniques
The nurse is entering data in the electronic medical record. The computer terminal is located on a rolling cart in the hallway. Which action by the nurse is most likely to result in a possible breach of confidentiality of medical records?
Entering the data on assigned client.
Recording the client history of an abortion.
Checking lab results.
Failing to log out of the terminal before walking away.
A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first?
Try to convince the client to proceed with the plans for surgery.
Tell the client you will notify the surgery department to cancel immediately.
Tell the client that the primary healthcare provider will be notified immediately.
Suggest that the client talk over the decision with family members.
The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care?
Identify a new goal for the client since this one has not been achieved.
Consider new nursing interventions for achievement of the goal if the condition still warrants it.
Determine that the nursing interventions were performed as planned.
Allow more time for achievement of the goal.
A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future?
Assign specific staff to check on each client during end-of-shift report.
Place newly admitted clients close to the nursing station.
Monitor level of suicide precaution needed on each client daily.
Ask clients to check on each other throughout the shift.
All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse?
Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour.
One hour postpartum client with a continuous trickle of vaginal bleeding.
2 hours postpartum client reporting intense perineal pain.
Client at 36 weeks gestation with a blood pressure of 148/92.
The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first?
Client with somatoform disorder.
Client with depression.
Client with panic attacks.
Client on suicide precautions.
The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative floor. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan?
The nurse did not trust the new UAP.
The nurse prefers to check all vital signs on her clients.
The nurse's role includes assessment of vital signs of post-op clients.
The nurse does not know the skills of the new UAP.
What resource should the nurse consult to determine the standards of care for an institution?
Organizational chart
Personnel policies
Policies and procedure manual
Job descriptions
A disoriented client is admitted to the med-surg unit with a diagnosis of acute renal failure. The client's spouse presents the nurse with an advance directive that gives instructions that no hemodialysis treatment is to be provided. What is the appropriate immediate action for the nurse to take at this time?
Inform the primary healthcare provider immediately of the advance directive and the client's wishes regarding no hemodialysis treatment. Place a copy of the advance directive in the client's medical record.
Obtain consent from the client's spouse for placement of the hemodialysis line and for acute hemodialysis.
Inform the client's spouse of the reason for the hemodialysis.
Tell the client's spouse to speak with the primary healthcare provider in order to make an informed decision on whether or not to proceed with hemodialysis.
The nurse notices that the primary healthcare provider, who has been looking at his client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse?
The nurse should immediately log the primary healthcare provider off the facility's health information system.
The nurse should immediately minimize or hide the screen so that the client information is not longer visible, and then ask the primary healthcare provider if he will be returning to the computer work station.
Which client should the nurse see first after receiving report on assigned clients?
Crushing chest pain.
Needing an IV started for the administration of blood.
Crying with pain after back surgery.
Waiting to go for a cardiac catheterization.
A nurse delegated ambulation of a client to the unlicensed assistive personnel (UAP). The next day, it was noted by the family that the client was not ambulated on the nurse's shift. What delegation error was made by the nurse?
Failure to delegate to the right person.
Failure to delegate under the right circumstance.
Failure to communicate.
Failure to adequately supervise and evaluate.
An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client?
All client appointment calls are transferred to the scheduling clerk.
The client will have to speak to the primary healthcare provider.
A copy of the record can be obtained within 24 hours of the request.
Medical records must stay within the facility unless requested by another primary healthcare provider.
Which assignments would be most appropriate for the RN to delegate to an LPN/VN? Select all that apply:
Six year old with new onset diabetes.
Ten year old with pneumonia admitted two days ago.
Three month old admitted with severe dehydration.
Four year old admitted for developmental studies.
Twelve year old with post op wound infection taking oral antibiotics.
After reviewing her assignment, the LPN/VN tells the RN her assignment is very unfair and requests that some of her clients be redistributed to the other staff. What should the RN do?
Ask the LPN/VN what her concerns are regarding her assignment.
Remove one of the LPN/VN's clients and take the client as part of her load.
Encourage the LPN/VN to use her teamwork skills in caring for her clients.
Explain to the LPN/VN that everyone has a heavy load and to change the assignments now would not be possible.
What assignment would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
Teaching the client perineal care.
Changing a colostomy bag on a client.
Serving the diet tray for a diabetic client.
Taking the initial vital signs on a client who is to receive blood.
After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse her load is too heavy and that she needs to reassign at least one of her clients to another nurse. What is the best response by the charge nurse?
Offer to take one of her clients.
Notify the nursing supervisor of the situation.
Ask the RN the reason she thinks her assignment is too heavy.
Explain to the RN that all the nurses have the same number of clients.
A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units of blood. What should the nurse do?
Prepare the client for the administration of blood.
Explain to the primary healthcare provider that the client's faith prohibits blood transfusions.
Explain to the client that the blood transfusions are needed for return to health.
Try to convince the client to accept the transfusions.
An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this?
Encourage the family to accept nursing home placement as the best option for their loved one.
Listen to the family's concerns and report those to the primary healthcare provider.
Ask the client what she wants and tell the family to abide by the client's wishes.
Realize that the nurse does not need to be involved in this decision.
The charge nurse notices that a certain staff nurse verbally attacks a client that was admitted with a history of being sexually abused. Further investigation reveals that the staff nurse was sexually abused as a child. Which action would the charge nurse take in making assignments?
Assign the nurse to this client, so the charge nurse may receive feedback from the client about the nurse's behavior.
Allow the nurse to decide if the nurse will take care of the client.
Assign another nurse to the client.
Co-assign the client to the nurse and a licensed practical nurse.
The nurse is working in a facility that uses the electronic medical record. The nurse is very busy and needs information about the health history of one of the assigned clients. One of the volunteers on the unit is a computer whiz, so he asks the nurse for login information so that he can get the information. What should the nurse do?
Enter the personal password and allow the volunteer to retrieve the information.
Tell the volunteer that only staff have access.
Tell the volunteer the password and allow the volunteer to retrieve the information.
Obtain the information at the end of the shift.
A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Which primary healthcare provider prescription will the nurse perform first?
Initiate oxygen at 2 liters/nasal cannula.
Start an IV of NS at 150 ml/hr.
Insert NG tube to low suction.
Attach client to the ECG monitor.
The emergency department called the LDR to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate?
Request that the emergency department hold the client until one of the RNs is available to do the initial assessment.
Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse.
Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client.
Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.
Which statements should a nurse make when educating a client about advance directives? Select all that apply:
Used as guidelines for client treatment should the client's family deem them necessary.
Legally binding documents.
Will be placed in the client's medical record.
Specifies a client's wishes for healthcare treatment should the client become incapacitated.
Allows the client's spouse to make end-of-life decisions.
A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate?
Your children are correct. The open heart surgery is the best thing for your health.
You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery.
I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery.
You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns
A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which is the best action by the nurse?
Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives.
Immediately inform the primary healthcare provider that the client requests additional information related to the bronchoscopy procedure.
