Charge nurse discovers staff nurse has made repeated medication errors. Which of the following actions should take 1st

Ask the nurse to describe her medication administration procedure

Which of the following statements by the client indicates an understanding of the teaching anout TB?

I should have a sputum culture done every 2 to 4 weeks

Which of the following clients should the nurse evacuate first?

A client who is receiving IV chemotherapy and is ambulatory

The nurse should explain that which of the following is an objective of telehealth?

Establishing communication between providers

Which of the following client statements indicates to the nurse an understanding of the pulmonary function test?

I might have to wear a nose clip during this test

Which of the following statements by a staff nurse indicates that the teaching about informed consent was effective?

Consent can be given by a durable power of attorney

Information for discharge teaching about total knee athroplasty should include

Contact information for the physical therapist, Information about follow-up care

A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?

Client who had cardiac catheterization capillary refill in great toe is 4s

Which of the following assessments should the nurse make before delegating care?

Has data been collected about specific client needs related to turning?

Which of the following clients should the nurse recommend to be examined first?

An older adult client who has dyspnea and a respiratory rate of 26/min

Which of the following should nurse identify as an indication that a referral to an occupation therapist is necessary?

I will need assistance with bathing

Results for documenting client education are low. Which of the following strategies should nurse manager implement first

Determine factors that interfere with the documentation of client education

Which of the following statements by a staff nurse indicates understanding?

HIPAA allows clients to request a review of their own medical records

The nurse should explain that advance directives include which of the following?

Instructions regarding treatments the client desires or does not desire

Nurse observes AP administer enema. For which of the following actions by the AP should the nurse intervene?

Position the client on her left side with knees flexed

Patient refuses surgery, partner wants surgery. Which is the deciding factor in determining if the surgery will be done?

Whether the client understands the risk of refusing the procedure

Which of the following is an appropriate procedure for taking care of aclient's ring?

Place the client's ring in the facility safe

Which of the following information should the nurse include in the teaching as an example of advocacy?

Recommending a referral for a client who requires physical therapy

Which of the following tasks should the nurse assign to the LPN?

Reinforcing teaching w a client who is learning to selfadminister insulin

Nurse observes AP incorrectly transfer client. Which of the following actions should the nurse take first?

Refer the AP to the facility procedure manual

A charge nurse suspects staff nurse is chemically impaired. Which of the following actions should the charge nurse take?

Collect data about the staff nurse to support further action

A nurse is planning care for a client who has Addison's disease. Which of the tasks should nurse plan to delegate to AP

Remind the client to change positions slowly

A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?

Obtaining a stool sample from a client who has renal failure

A charge nurse is receiving change-of-shift report. Which of the following situations should charge nurse address first?

The emergency department nurse is waiting to give report on a new admission

Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Teaching a client to perform a fingerstick for testing blood glucose levels

Which of the following can be delegated to an assistive personnel for an elderly pt waiting surgery for fractures hip?

Recording the client's vital signs

Which of the following tasks is appropriate to assign to a licensed practical nurse?

Administer a nasogastric tube feeding

A nurse is teaching client how to use glucometer at home. Which of the following instructions should the nurse include?

Obtain the blood sample from the finger pads

The nurse should recognize that which of the following clients is the highest priority?

A client who has PVD and has an absent pedal pulse in the right foot

16 y/o has ruptured appendix and requires emergency sx. Accompanied by adult neightbor. What actions should nurse take?

Attempt to notify the client's guardian to obtain consent

Two staff nurses do not take meal breaks. Which of the following actions should the nurse take first?

Determine the reasons the nurses are not taking scheduled breaks

The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions?

Refer the client to the social services department

When client's partner asks how respite service can help, which of the following responses by the nurse is appropriate?

It makes it possible for you to have time away from caring for your wife

A nurse delegates vitals to an AP. Which of the following actions should the nurse take to evaluate the delegated task?

Recheck vital signs that are outside the expected reference range

Two nurses having loud convo at nurses station about care for a patient. Which of the following actions?

Escort the nurses to the nurses' lounge to continue the discussion

Which of the following statements by a nurse indicates an understanding of the role of a client advocate?

Empower the clients to make informed healthcare decisions

Nurse administers opioid+benzodiazepine, client becomes somnolent and difficult to arouse. What action should nurse take

Contact the provider about replacing the opioid with an NSAID

Just before procedure, client asks nurse about risks of procedure. Which of the following actions should the nurse take?

Notify the provider about the client's concerns

Which of the following clients should the nurse assess first?

A client who reports indigestion and pain in her jaw

ER charge is supervising nurse floating from med/surg. Which of the following assignments is appropriate for the float?

Perform a urinary catheterization for a client who has experienced CVA

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Questions 70

Answers

1
Client is receiving too much IV fluid because IV pump is not working. Which of the actions should the nurse take first?
Notify the provider
Complete an incident report
Auscultate the client's lungs
Place a faulty equipment tag on the pump
2
Charge nurse discovers staff nurse has made repeated medication errors. Which of the following actions should take 1st
Identify education opportunities for the nurse regarding safe medication
Review with the nurse the principles of medication administration
Ask the nurse to describe her medication administration procedure
Notify the risk management department of the situation.
3
Which of the following statements by the client indicates an understanding of the teaching anout TB?
I need to have a TB skin test done once per year
I should wear a mask while around my family
I should have a sputum culture done every 2 to 4 weeks
I need to take my prescribed medication for 3 months
4
Which of the following clients should the nurse evacuate first?
A client 1 day postoperative following thoracic surgery and chest tube
A client who is confused and restrained for safety
A client who is receiving IV chemotherapy and is ambulatory
A client who is in Buck's traction for a left hip fracture
5
The nurse should explain that which of the following is an objective of telehealth?
Assessing client needs
Providing medication reconciliation
Establishing communication between providers
Developing client treatment protocols
6
Which of the following client statements indicates to the nurse an understanding of the pulmonary function test?
I will run on a treadmill during this test
I might have to wear a nose clip during this test
I might have a tube inserted into my airway during the test
I will be given contrast dye during this test
7
Which of the following statements by a staff nurse indicates that the teaching about informed consent was effective?
Guardian consent is required for an emancipated minor
The nurse can answer any questions the client has about the procedure
A family member can interpret informed consent from a client who is deaf
Consent can be given by a durable power of attorney
8
Information for discharge teaching about total knee athroplasty should include
Advance directives information
Contact information for the physical therapist
Medication guidelines information
Information about follow-up care
9
A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?
A client who has COPD and has an oxygen saturation of 90%
A client who had a cholecystectomy 6 hr ago and is requesting pain med
A client whose TPN was discontinued 4 hr ago and is requesting clear liquid
Client who had cardiac catheterization capillary refill in great toe is 4s
10
Which of the following assessments should the nurse make before delegating care?
Has data been collected about specific client needs related to turning?
Does AP have time to change clients central IV line dressing after turning?
Has the AP checked the client's pain level prior to turning her?
Is client's family present so the AP can show them how to turn the client?
11
Which of the following clients should the nurse recommend to be examined first?
A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood
An older adult client who has dyspnea and a respiratory rate of 26/min
An adult client who has large ecchymosis on both legs
An adolescent client who has an injured ankle and reports a pain level of 8
12
Which of the following should nurse identify as an indication that a referral to an occupation therapist is necessary?
I will need assistance with bathing
I am tired of having pain in my joints all the time
I need some help planning my meals to maintain my weight
I'm having difficulty climbing the stairs at my house
13
Results for documenting client education are low. Which of the following strategies should nurse manager implement first
Offer incentives for the staff once the unit's results are back
Determine factors that interfere with the documentation of client education
Train LPNs to reinforce teaching w clients using standardized teaching plan
Include documentation of client education as part nurses annual performance
14
Which of the following statements by a staff nurse indicates understanding?
HIPAA allows clients to request a review of their own medical records
HIPAA allows facilityspecific coding of client health care info for privacy
HIPAA prohibits uploading photographs of clients providers to social media
Clients who participate in research studies forfeit HIPAA right to privacy
15
The nurse should explain that advance directives include which of the following?
Instructions regarding treatments the client desires or does not desire
A form with directions for contacting next of kin
Information regarding the disposition of the client's body upon death
Information regarding organ donation
16
Progress report falsey idenitifies client as HIV+ due to multiple sex partners. Nurse manager should identify
Negligence
Battery
Libel
Slander
17
Nurse observes AP administer enema. For which of the following actions by the AP should the nurse intervene?
Administers the solution at room temperature
Inserts the tubing 8 cm (3.1 in) into the rectum
Points tubing in the direction of the umbilicus during insertion
Position the client on her left side with knees flexed
18
Patient refuses surgery, partner wants surgery. Which is the deciding factor in determining if the surgery will be done?
Whether the client understands the risk of refusing the procedure
Whether the facility ethics committee reached a consensus on the case
Whether the partner is client's durable power of attorney for health care
Whether the client's refusal is based on religious belief
19
Which of the following is an appropriate procedure for taking care of aclient's ring?
Place the ring in the bad with the client's clothing
Tape the ring securely to the client's finger
Place the client's ring in the facility safe
Agree to keep the ring for the client until after surgery
20
Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions?
Mumps
Rubeola
Varicella
Rotavirus
21
Which of the following information should the nurse include in the teaching as an example of advocacy?
Suggesting a client's partner attend a support group for emotional support
Evaluating a client's home for safety hazards
Completing an incident report following a medication error
Recommending a referral for a client who requires physical therapy
22
Which of the following tasks should the nurse assign to the LPN?
Reinforcing teaching w a client who is learning to selfadminister insulin
Admitting a new client who has chronic back pain to the unit
Ambulating a client who is scheduled for discharge later in the day
Administering morphine IV bolus to a client who is __ hr postoperative
23
Nurse observes AP incorrectly transfer client. Which of the following actions should the nurse take first?
Refer the AP to the facility procedure manual
Instruct the AP to request assistance when unsure about a task
Demonstrate the proper client transfer technique for the AP
Help the AP assist the client with the transfer
24
A charge nurse suspects staff nurse is chemically impaired. Which of the following actions should the charge nurse take?
Report the staff nurse to the facility ethics committee
Collect data about the staff nurse to support further action
Assign clients who are not prescribed narcotics to the staff nurse
Counsel the staff nurse about substance use
25
A nurse is planning care for a client who has Addison's disease. Which of the tasks should nurse plan to delegate to AP
Remind the client to change positions slowly
Determine the client's muscle strength prior to ambulation
Decide how often to measure vital signs
Explain to the client about a 24-hr urine specimen collection
26
A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
Assessing a client who just returned from hemodialysis
Monitoring a client who has a fluid restriction
Obtaining a stool sample from a client who has renal failure
Reviewing dietary instructions for a client who has kidney stones
27
A charge nurse is receiving change-of-shift report. Which of the following situations should charge nurse address first?
The emergency department nurse is waiting to give report on a new admission
Two staff members have called to say they will be absent
nurse on the previous shift wrote an incident report about medication error
Transport assistance is unavailable to take client to occupational therapy
28
Which of the following diseases should the nurse report to the state health department?
Pertussis
Group B streptococcal disease
Respiratory syncytial virus
Rotavirus
29
When using SBAR, which of the following information should the nurse include in the background portion of the report?
The client's code status
A prescribed consultation
The client's vital signs
The client's name
30
Which of the following tasks should the nurse plan to delegate to an assistive personnel?
Advising a client on self-administration of acetaminophen
Performing post mortem care prior to transferring the client to the morgue
Informing a family of a client's progress in physical therapy
Teaching a client to perform a fingerstick for testing blood glucose levels
31
Which of the following can be delegated to an assistive personnel for an elderly pt waiting surgery for fractures hip?
Recording the client's vital signs
Turning the client
Checking the pulses of the client's right foot
Determining the client's pain level
32
Which of the following tasks is appropriate to assign to a licensed practical nurse?
Administer a nasogastric tube feeding
Pick up the meal trays after lunch
Determine adequacy of ventilator settings
Plan break times for assisstive personnel
33
A nurse in a long-term care facility should identify that which will provide security for clients who have dementia?
Setting alarms on exits
Restricting space to reduce pacing
Using a facility
Turning off room lights at night
34
A nurse is teaching client how to use glucometer at home. Which of the following instructions should the nurse include?
Elevate the arm for 1 min before taking the blood sample
Obtain the blood sample from the finger pads
Warm the hands prior to piercing the skin.
Cap the lancet prior to putting it in the trash
35
The nurse should recognize that which of the following clients is the highest priority?
newly diagnosed with pancreatic cancer and is scheduled to begin IV chemo
A client who has PVD and has an absent pedal pulse in the right foot
A client who is postop following a laminectomy 12 hr ago and cannot void
A client who has MRSA and an axillary temperature of 101F
36
Nurse notices client received additional dose of medication. Which of the following actions should the nurse take first?
Observe the client's condition
Complete an incident report
Inform the nursing supervisor
Notify the provider
37
Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?
Determine client care goals
Document assessment data
Review the client's new laboratory values
Complete required tasks
38
Which of the following solutions should the nurse recommend to clean the equipment after CDIFF?
Chlorine bleach
Triclosan
Chlorhexidine
Isopropyl alcohol
39
16 y/o has ruptured appendix and requires emergency sx. Accompanied by adult neightbor. What actions should nurse take?
Ask the adult neighbor to sign the consent form
Attempt to notify the client's guardian to obtain consent
Obtain consent from the hospital administrator
Witness the client signing the consent form
40
Two staff nurses do not take meal breaks. Which of the following actions should the nurse take first?
Provide coverage for the nurses' breaks
Determine the reasons the nurses are not taking scheduled breaks
Discuss time management strategies with the nurses
Review facility policies for taking scheduled breaks
41
The nurse should explain that preventing client injury by removing a fall hazard demonstrates which ethical principle?
Autonomy
Nonmaleficence
Veracity
Utility
42
The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions?
Recommend the client reuse the testing lancets
Refer the client to the social services department
Ask the provider about the possibility of less frequent monitoring
Provide the client with a week's worth of supplies from the hospital
43
Nurse finds pile of newspapers in clients home+explains need to discard for safety+client agrees. What strategy was used
Compromising
Collaborating
Accommodating
Smoothing
44
When client's partner asks how respite service can help, which of the following responses by the nurse is appropriate?
This service delivers meals and supplies to reduce errands away from home
Service offers psychological interventions during+after your wife's illness
It makes it possible for you to have time away from caring for your wife
The clinicians help reduce the severity of your wife's physical problems
45
A nurse delegates vitals to an AP. Which of the following actions should the nurse take to evaluate the delegated task?
Review vital sign trends at the end of the shift
Ask the AP to write a summary of the delegated tasks during the shift
Recheck vital signs that are outside the expected reference range
Compare the vital signs with those taken by another AP on a previous shift
46
Two nurses having loud convo at nurses station about care for a patient. Which of the following actions?
Escort the nurses to the nurses' lounge to continue the discussion
Recommend that both nurses be terminated
Contact the house supervisor to mediate the conflict
Make arrangements to take over the client's care
47
Which of the following statements by a nurse indicates an understanding of the role of a client advocate?
I should take responsibility for coordinating clients care
Empower the clients to make informed healthcare decisions
I will adhere to the provider's prescribed treatments
I will suggest the best course of action for clients who are indecisive
48
Nurse administers opioid+benzodiazepine, client becomes somnolent and difficult to arouse. What action should nurse take
Administer the benzodiazepine but withhold the opioid
Withhold the benzodiazepine but continue the opioid
Contact the provider about replacing the opioid with an NSAID
Continue the medication dosages that relieve the client's pain
49
Just before procedure, client asks nurse about risks of procedure. Which of the following actions should the nurse take?
Check if medical record indicates provider explained procedure to client
Notify the provider about the client's concerns
Explain the risks of the procedure to the client
Convey the client's request to the nurse who witnessed the consent
50
Which of the following clients should the nurse assess first?
A client who reports indigestion and pain in her jaw
A client who reports a headache with sensitivity to light
A client who reports an urge to void but has not urinated
A client who reports feeling lightheaded when stands up from lying position
51
ER charge is supervising nurse floating from med/surg. Which of the following assignments is appropriate for the float?
Administer IV nitroglycerin to a client who is experiencing chest pain
Perform a urinary catheterization for a client who has experienced CVA
Set up a trauma room for an incoming client who was in a motorvehicle crash
Complete a SADPERSONS assessment scale for client who has attempted suicide
52
Which of the following resources is the highest priority to have available in response to a bioterrorism event?
A mental health specialist on the response team
A network for communication between staff members and families
A sufficient supply of personal protective equipment
A system for tracking client information
53
For which of the following clients should the nurse collaborate with the facility ethics committee?
An adolescent client whose parents refuse blood transfusion for religious
A middle adult client who leaves the facility against medical advice
An older adult client who has advanced directives on file
A young adult client who is participating in a medical research study
54
Which of the following actions indicates the newly licensed nurse is maintaining sterile technique?
Opens the sterile pack by first unfolding the top flap away from her body
Places sterile items within 0.5 in) border around edges of sterile field
Prepares container of sterile solution onfield after putting sterile gloves
Removes outside packaging instrument before dropping it on sterile field
55
Which of the following infections should the nurse report to the state health department?
Impetigo contagiosa
Pediculosis capitis
Candida albicans
Chlamydia trachomatis
56
Client is unconscious and finds son reading EMR from bedside. Which of the following actions should the nurse take first
Logout computer so the client's son cannot view his mother's information
Report possible violation of client confidentiality to the nurse manager
Recommend son meet with provider to get info about his mother's condition
Complete incident report regarding breach of the client's confidentiality
57
The client arrives to ED disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
Notify risk management before initiating treatment
Proceed with treatment without obtaining written consent
Contact the client's next of kin to obtain consent for treatment
Have the client sign a consent for treatment
58
Which of the following is an appropriate task for the AP?
Answer the parents' questions about newborn circumcision
Obtain the weight of a newborn that is receiving formula
Inspect the skin of a newborn who is receiving phototherapy
Show a new mother how to change the newborn's diaper
59
Which of the following clients should the nurse recommend for treatment first?
A client who has a neck injury and is unable to breathe spontaneously
A client who has two open chest wounds with a left tracheal deviation
A client who has bipolar disorder and is exhibiting signs of hallucination
A client who has major burns over 75% of her body surface area
60
A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first?
Administer RH immune globulin to a client who is Rhnegative+6 hr postpartum
Instruct a client who has an episiotomy about a sitz bath
Assist a client who requests help breastfeeding her 4-hr-old newborn
Check uterine tone for a client who received methylergonovine
61
Which of the following findings should the nurse identify as increasing the client's risk for falls?
A folding chair without arm rests
A two-wheeled walker used to assist the client with ambulation
A wheeled office chair at the client's computer desk
A throw rug covering some cracked vinyl flooring in the kitchen
62
After donning sterile gown&gloves, which of the actions by newly licensed nurse demonstrates correct aseptic technique?
The nurse holds her hands above her waist
The nurse applies goggles
The nurse puts on a face mask
The nurse turns her back to the sterile field
63
Client refuses to provide urine specimen after suspected drug use in a motor-vehicle crash. Appropriate action?
Assess the client for urinary retention
Tell the client that a catheter will be inserted
Document the client's refusal in the chart
Obtain a provider's prescription for a blood alcohol level
64
Which of the following statements indicates an understanding of the teaching about restraints?
A provider can write a prescription for restraints 'as needed'
I will remove a client's restraints every 4 hours
I should tie the restraints using a square knot
I need to tie the restraint to the part of the bed frame that moves
65
Which of the following tasks should the nurse assign to a licensed practical nurse?
Obtain vital signs
Administer a hepatitis B vaccine
Conduct the newborn hearing screening
Perform a New Ballard screening
66
A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has a new diagnosis of Graves' and TSH level of 0.2 mu/mL
A client who has a nasogastric tube and has crackles in the lungs
A client who has congestive heart failure and has lost 2 lb in the 24 hr
A client who has diabetes mellitus and reports paresthesia in fingers/toes
67
Which of the following findings should indicate the need for referral to an occupational therapist after stroke?
Receptive aphasia
Facial drooping
Memory loss
Unilateral neglect
68
New nurse floats to unfamiliar unit and does not feel safe to care for clients. Which of the following actions?
Notify the risk manager.
Document the concern in the nurse's notes
Accept the assignment with help from assistive personnel on the unit
Request that the charge nurse modify the assignment
69
The client and her partner are asking the nurse about hospice care. Which of the statements by the nurse is appropriate?
Hospice care is multidisciplinary program for clients who are terminally il
Hospital access is no longer available for clients who are in hospice care
Hospice care is helpful for clients at various stages of chronic illness
Hospice care prolongs the life expectancy of clients who are terminally ill
70
The nurse suspects elder abuse. Which of the following actions should the nurse take?
File an incident report
Treat and discharge the client
Ask the client's son to go to the waiting area
Ask the client about his injuries with the son present

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