Nursing10015c NCLEX Module 5 Exam Questions / Answers with Detailed Explanations, Exams of Nursing

Download Nursing10015c NCLEX Module 5 Exam Questions / Answers with Detailed Explanations and more Exams Nursing in PDF only on Docsity! Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Nursing10015c NCLEX Module 5 Exam Questions / Answers with Detailed Explanations 1. 1.ID: 22114995478 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the strategic words “least possible harm“ in the question and the definition of nonmaleficence. Review: Nonmaleficience Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/LegalAwarded 96.0 points out of 96.0 possible points. 2. 2.ID: 22114995475 Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. Review: false imprisonment Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review: Beneficence Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/LegalAwarded 96.0 points out of 96.0 possible points. 3. 3.ID: 22114995472 The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Awarded 96.0 points out of 96.0 possible points. 4. 4.ID: 22114995469 The nurse and an assistive personnel (AP) enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,“ audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,“ audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the strategic word “retrospective“ in the question and the description in the correct option. Review: quality improvement and retrospective and concurrent audits Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Health Care Quality, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Quality Improvement/Health Care Quality Awarded 96.0 points out of 96.0 possible points. 8. 8.ID: 22114995457 The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure record. While transcribing the prescription, the nurse notes that the prescribed dose is three Rationale: The nurse must follow the primaary health care provider’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the primary health care provider is necessary. If the primary health care provider confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication. Test-Taking Strategy: Focus on the subject, primary health care provider who writes a prescription that is three times higher than the recommended dose. Eliminate the options that are comparable or alike in that they indicate that the medication would be administered. Review: primary health cae provider’s prescriptions Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal times higher than the recommended dose. The nurse calls the primary health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take? A. Contact the nursing supervisor Correct B. Continue to transcribe the prescription C. Ask the nurse assigned to care for the client to administer the medication D. Verify the prescribed dose with the client before administering the medication Awarded 96.0 points out of 96.0 possible points. 12. 12.ID: 22114995406 The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the primary health care provider. The primary health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the primary health care provider that removal of a chest tube is not a nursing procedure Correct D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube Rationale: Telephone prescriptions involve a primary health care provider’s dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the physician. The nurse then writes the prescription on the physician’s prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the primary health care provider who gave the telephone prescription and clarify the prescription. Test-Taking Strategy: Focus on the subject, incomplete primary health care Rationale: Actual removal of a chest tube is the duty of a primary health care provider. Therefore, the nurse would first inform the primary health care provider that this is not a nursing procedure. If the primary health care provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agency’s policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse. Test-Taking Strategy: Focus on the subject, nurse asked to remove a chest tube. Eliminate the options that are comparable or alike in that they indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word “first.“ The nurse should discuss the prescription with the physician. Review: chest tubes Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/LegalAwarded 96.0 points out of 96.0 possible points. 13. 13.ID: 22114995403 The nurse calls a primary health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The primary health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Call the primary health care provider who gave the telephone prescription to clarify the prescription Correct B. Call the nursing supervisor for assistance in determining the route of administration C. Administer the medication intravenously, because this route is generally used for clients with CHF D. Administer the medication orally and clarifying the prescription once the primary health care provider has finished caring for the client in the emergency department Rationale: Battery is any intentional touching of a client without the client’s consent. Such contact may be harmful to the client or it may merely be offensive to the client’s dignity. If a nurse discovers that battery of a client has occurred, the nurse should report the situation to the nursing supervisor. Telling the client that the nurse did the right thing in giving the enema is incorrect, because the other nurse has violated the client’s rights. Confronting the nurse and telling her that she is going to be charged with battery would likely result in unnecessary conflict. Although the primary health care provider may need to be notified, the nurse should first report the situation to the nursing supervisor. Test-Taking Strategy: Focus on the subject, client rights,and note the strategic Rationale: Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client’s consent, the nurse may be charged with assault. Therefore, the nurse is not justified in administering the medication. Battery is any intentional touching without the client’s consent. Test-Taking Strategy: Focus on the data in the question and the nurse’s statement. Note that the nurse threatens the client. Next, recall the definition of assault, which will direct you to the correct option. Review: client rights Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal intramuscular injection.” Which statement accurately describes the nurse’s response to the client? A. The nurse could be charged with battery. B. The nurse could be charged with assault. Correct C. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician. Awarded 96.0 points out of 96.0 possible points. 17. 17.ID: 22114994091 The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take? A. Contact the client’s primary health care provider B. Report the incident to the nursing supervisor Correct C. Tell the client that the nurse did the right thing in giving the enema D. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made an error or performed an incorrect action or procedure. If a primary health care provider’s prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Test-Taking Strategy: Focus on the subject, primary health care provider changing his/her prescription. Eliminate the options that are comparable or alike in that they indicate that the primary health care provider made an error in writing a prescription. These options contain the words “error“ or “incorrect.“ Review: documentation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal words “most appropriate.“ Recalling that any situation that constitutes a violation of a client’s rights needs to be reported and remembering the organizational channels of reporting will direct you to the correct option. Review: battery Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Elimination, Health Care Law Awarded 96.0 points out of 96.0 possible points. 18. 18.ID: 22114994088 The nurse calls a primary health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The primary health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes? A. The primary health care provider was called to clarify the prescription for morphine sulfate. Correct B. The primary health care provider made an error in the written prescription for morphine sulfate. C. The primary health care provider was called to correct an error in the dosage of morphine sulfate. D. An incorrect dosage of morphine sulfate was prescribed and the primary health care provider was notified. Awarded 96.0 points out of 96.0 possible points. 19. 19.ID: 22114994085 The charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriate action for the charge nurse to take? A. Contact the nursing supervisor Correct B. Ask the staff member how much alcohol she has consumed C. Tell the staff member that she is not allowed to administer medications D. Ask the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off Incorrect Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs/symptoms objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are signs/symptoms of intoxication. Client safety is the primary concern. After contacting the nursing supervisor, the intoxicated nurse is removed from the situation, confronted briefly and firmly about the behavior, and sent home to rest and recuperate. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident after returning to work. Refusal to sign and date the memo should be noted by the charge nurse and a witness. Neither asking the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing the client’s safety. Asking the staff member how much alcohol he/she has consumed is confrontational and irrelevant. Test-Taking Strategy: Keep in mind that client safety is the priority. Asking the staff member how much alcohol he/she has consumed is irrelevant, so eliminate this option. Next eliminate the options that are comparable or alike in that they do not involve removal of the staff member from the client care area. Review: substance abuse in staff Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Health Care Policy, Leadership HESI Concepts: Health Policy/Systems—Health Care Policy, Collaboration/Managing Care—Leadership Awarded 0.0 points out of 96.0 possible points. 20. 20.ID: 22114994082 A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client? A. That anatomical gifts should be made in writing and signed Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client’s decision. Therefore the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate and represent violations of the client’s rights. Telling the client that the primary health care provider will be informed of the refusal of care is a threatening action on the nurse’s part. Test-Taking Strategy: Focus on the subject, client refusing a bed bath. Remember your knowledge of client rights and note the strategic word appropriate. This word refers to the best option. Eliminate the options that present a threat to the client or indicate that the bath will be given regardless of the client’s wishes. Review: client rights Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgement, Ethics HESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional medication. Note the strategic word “appropriate.“ Eliminate the option that refers the client to the physician, because it places the client’s question on hold. To select from the remaining choices, find the option that is most complete and thorough. Review: client rights Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Client Education, Health Care Law HESI Concepts: Health Policy/Systems—Health Care Law, Teaching and Learning/Client EducationAwarded 96.0 points out of 96.0 possible points. 22. 22.ID: 22114994076 A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate? A. Telling the nursing student to allow the client to rest Correct B. Telling the nursing student to give the client the bath anyway C. Telling the client that the primary health care provider will be informed of the refusal of care D. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Awarded 96.0 points out of 96.0 possible points. Rationale: Privacy is a client’s right to be free from unwanted intrusion into his or her private affairs. Videotaping constitutes an invasion of a client’s privacy, and written permission is required from the client for an action such Rationale: Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the appropriate response is to tell the client’s wife that she will have to discuss the test with the client. Likewise, a client’s medical record is confidential and cannot be given to the wife for reading. Telling the client’s wife that the radiology department is unclear as to what test has been prescribed is inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on another department. Test-Taking Strategy: Focusing on the subject, confidentiality, and recalling the issues surrounding confidentiality will direct you to the correct option. Review: confidentiality Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal 23. 23.ID: 22114994073 A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A. A bone scan is being performed. B. She will have to discuss the prescribed test with the client. Correct C. The radiology department is not clear as to which test has been prescribed. D. She can read the client’s medical record to determine what the primary health care provider prescribed. Awarded 96.0 points out of 96.0 possible points. 24. 24.ID: 22114994070 A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. What is the best action by the nurse conducting the program? A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed Correct C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization videotaping. Therefore the nurse must explain to the television crew that videotaping is not allowed. The other options are incorrect and constitute invasions of client privacy. Test-Taking Strategy: Focus on the subject, client privacy. Note the strategic word best because ths refers to the option that is the most apporpriate response. Eliminate the options that are comparable or alike in that they represent invasions of client privacy. Review: client privacy Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 96.0 points out of 96.0 possible points. 25. 25.ID: 22114994067 A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? A. “Oh, really? I didn’t see that!” B. “We can’t discuss a client’s medical condition.” Correct C. “Yes, that’s why we’ve imposed contact precautions.” D. “Yes, he does, but be sure not to discuss this with anyone else.” Rationale: A client’s medical condition is confidential and should never be discussed with anyone other than the client and the client’s primary health care provider. Therefore the nurse must tell the unit secretary that the client’s condition is not to be discussed. The statements “Yes, he does, but be sure not to discuss this with anyone else“ and “Yes, that’s why we’ve imposed contact precautions“ both confirm the client’s disease and are therefore inappropriate. Responding, “Oh, really? I didn’t see that!“ promotes further discussion of the client’s condition and is inappropriate. Test-Taking Strategy: Focus on the subject, discussing a client’s medical record with the unit secretary, and recall the issues surrounding confidentiality. This will help you eliminate the option that promotes further discussion of the client’s condition. Next, eliminate the options that are comparable or alike in that they confirm the client’s illness. Review: confidentiality Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 96.0 points out of 96.0 possible points. Rationale: Further education is needed if the nurse does everything if the client stops breating. In a situation in which a client has no family members who can provide permission for treatment, the primary health care provider may write a DNR order if he or she is reasonably and medically certain that resuscitation would be futile. This order has been ethically and legally put in place and should be reviewed according to hospital policy. However, the client’s other medical conditions must be treated. Test-Taking Strategy: Focus on the subject, need for further education. The written DNR order is ethical and legal and the nurse should not do everything if the client stops beating. The other options are true. Review: DNR Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Ethics HESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors- Professionalism Content Area: Ethical/Legal Giddens Concepts: Ethics, Leadership HESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Health Policy/Systems Awarded 96.0 points out of 96.0 possible points. 29. 29.ID: 22114994055 A man who is visiting his wife in a long-term care facility for people with Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital primary health care provider that the client has no other family members and that his wife is mentally incompetent. The client’s primary health care provider writes a DNR order. What knowledge by the registered nurse indicates a need for further education? A. That the client’s other medical conditions must be treated. B. That the DNR order has been ethically and legally implemented. C. That the DNR order will be reviewed according to hospital policy. Incorrect D. That everything possible must be done if the client stops breathing. Correct Awarded 0.0 points out of 96.0 possible points. 30. 30.ID: 22114994052 A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. What does the nurse know that a DNR order means? Select all that apply. A. That it must be legally and ethically implemented. Correct B. The DNR order may be changed once it is in effect Correct C. That CPR can be started but no medications can be administered. D. The DNR order requires frequent review as specified by state or agency policy Correct Rationale: If the client’s condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client’s hospitalization. The client’s request regarding DNR status is the priority. Test-Taking Strategy: Focus on the subject, the conditions of a DNR order. Know that the DNR order does not have to remain in effect for the duration of the client’s hospitalization. Also know that CPR as well as resuscitative medications should not be given if a DNR order is in place. Review: DNR Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Giddens Concepts: Ethics, Health Care Law HESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors- Professionalism E. The client is the responsible person who may change the DNR order. Correct F. The DNR order, as written on admission, must remain in effect for the duration of the client’s hospitalization Awarded 72.0 points out of 96.0 possible points. 31. 31.ID: 22114994049 A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A. A client who requires periodic suctioning B. A client who needs a colostomy irrigation C. A client who needs frequent ambulation with a walker Correct D. A client who has undergone an arteriogram and requires close monitoring Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed practical nurse (LPN) because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to either an LPN or an RN because these personnel have the knowledge and education to detect changes in the client’s status that require attention. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment to a nursing assistant. Eliminate the options that are comparable or alike in that they involve invasive procedures. To select from the remaining options, think about the education that a nursing assistant receives. The nursing assistant is Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client’s condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment of tasks to an LPN. Think about the activities that the LPN is able to perform. Next, eliminate the options that are comparable or alike in that they are noninvasive procedures. Review: delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical and education to assess and detect changes in a client’s status. Review: delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving Awarded 96.0 points out of 96.0 possible points. 32. 32.ID: 22114994046 A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments Correct D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures Awarded 96.0 points out of 96.0 possible points. 33. 33.ID: 22114994043 A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Not all staff members have the education, knowledge, and ability to make judgments about the tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up had been conducted and outcomes identified. It is not appropriate to assign the tasks that have not been completed to the next nursing shift; this action does not ensure that client needs will be met and also increases the workload for the next shift. Test-Taking Strategy: Focus on the subject, nurse’s primary responsiblity after delegating tasks. Use the process of elimination, noting the strategic words “primary responsibility.” Recalling that the ultimate responsibility for a task lies with the person about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure. Test-Taking Strategy: Focus on the subject, what client to assess first. Note the strategic word “first”. This indicates the client who is most important to assess. Use Maslow’s Hierarchy of Needs theory and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload. Review: Assessment priorities Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care En vironment Integrated Process: Nursing Process/Planning Content Area: Delegating/PrioritizingAwarded 96.0 points out of 96.0 possible points. 36. 36.ID: 22114994034 A nurse has delegated several nursing tasks to staff members. What is the nurse’s primary responsibility after delegation of these tasks? A. Documenting completion of each task B. Assigning any tasks that were not completed to the next nursing shift C. Allowing each staff member to make judgments when performing the tasks D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Correct Review: delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Care Coordination. Clinical Judgment Awarded 96.0 points out of 96.0 possible points. 37. 37.ID: 22114994031 A case manager is reviewing progress notes in a client’s medical record. Which notation indicates the need for follow-up? A.1 B. 2 Correct C.3 D.4 Rationale: Crackles heard in the lower lobes of the lungs in a client with heart failure are an unexpected and unwanted outcome requiring follow-up because they could indicate the development of pulmonary edema. A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of admission through, and after, discharge. This nurse initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care, evaluating and updating the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. The notations made for the other clients listed represent expected outcomes. Test- Taking Strategy: Think about the role of the case manager and read each notation carefully. Next, focus on the subject, and the strategic words the “need for follow-up”. This will direct you to the notation that represents an unexpected or unwanted outcome. Crackles heard in the lower lobes of the lungs on auscultation are a matter of concern. Review: Heart failure Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: S. No Client Condition Notation 1. Client 1 Status post–mastectomy:18 hours Five milliliters of bloody drainage was emptied from the Jackson-Pratt drain. 2. Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation. 3. Client 3 Status post– appendectomy: 24 hours The surgical dressing is clean and dry. Client 4 Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care Awarded 96.0 points out of 96.0 possible points. 38. 38.ID: 22114994028 The nurse reviewing a client’s record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? Client Medications 1. Atorvastatin 10 mg orally 2. Zolpidem 5 mg orally daily 3. Ferrous sulfate 1 tablet orally 4. Levothyroxine 137 mg orally A.1 B.2 C.3 D. 4 Correct Rationale: For adequate absorption, levothyroxine must be administered with water on an empty stomach as soon as the client awakens and at least 1 hour apart from other fluids (e.g., coffee or tea), food, and other medications. Therefore this medication should be administered first. Atorvastatin, an HMG– CoA reductase inhibitor used to lower cholesterol, is administered at bedtime because cholesterol synthesis is increased during the night. Zolpidem, a benzodiazepine-like medication used to enhance sleep, is administered at bedtime. Ferrous sulfate is an iron supplement that is administered with water between meals. Test-Taking Strategy: Note the strategic word “first.” Think about the classification of each medication to determine its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are comparable or alike in that they are administered at bedtime. Next, recalling the action of levothyroxine will direct you to this option. Review: Levothyroxine Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 96.0 points out of 96.0 possible points. 39. 39.ID: 22114994025 A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to deal with the conflict? A. Ignore the resistance Awarded 96.0 points out of 96.0 possible points. 42. 42.ID: 22114994016 A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will he/she plan to care for first? A. A client who is scheduled for surgery at 1 pm Correct B. A client scheduled for physical therapy at 11 am C. A client in skeletal traction who has just received pain medication D. A client who is able to perform activities of daily living independently Rationale: For the client assignment presented, the RN would plan to care for the client who is scheduled for surgery at 1 pm first. Several items need to be addressed before surgery, including client preparation (physical and emotional) and primary health care provider prescriptions, all of which will take time. Also, many times the operating room will make late changes in the schedule, depending on room and primary health care provider availability, and will request an earlier surgical time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client. The needs of the client who is independent and the client scheduled for physical therapy later in the morning are not high priorities. Test-Taking Strategy: Focus on the subject, the client for whom the RN will care first. Note the strategic word “first”. This indicates the most important client to care for at this time. Noting that an assigned client is scheduled for surgery and recalling the many needs of a client about to undergo surgery will direct you to the correct option. Review: prioritizing Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Care Coordination HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Quality Improvement-Health Care Quality Awarded 96.0 points out of 96.0 possible points. 43. 43.ID: 22114994013 A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow- up? Select all that apply. A. A client is performing his/her own colostomy irrigations. B. A client with a central venous catheter has a temperature of 100.6° F (38.1°C). Correct C. A client with a new diagnosis of diabetes mellitus is self- administering insulin. D. A client who has just undergone surgery has a urine output of more than 30 mL/hr. Rationale: An assessment activity is always the first step in the nursing process. Conducting a community survey on school violence addresses assessment of community perceptions. Teaching schoolchildren about the dangers of violence and distributing fliers that identify the cause of school violence are implementation measures. Looking at what other communities are doing is part of the analysis of a variety of assessment data but is not specific to the subject of the question. Test-Taking Strategy: Focus on the subject, interventions to help prevent violence. E. A client who has just undergone surgery is getting relief from the prescribed pain medication. Rationale: A temperature of 100.6° F (38.1°C) in a client with a central venous catheter is an unexpected and unwanted outcome requiring the need for follow-up, because it may indicate the development of an infection. A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. The other options all represent expected outcomes. Test-Taking Strategy: Think about the role of the case manager and read each client description carefully. Next, focus on the subject, an unexpected outcome and the strategic words “need for follow-up”. This indicates a negative event query and will direct you to the outcome that is unexpected or unwanted. An increased temperature is a concern because it is a sign of infection. Review: dealing with unexpected outcomes Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Giddens Concepts: Professional Identity, Care Coordination HESI Concepts: Professional Behaviors-Professionalism, Collaboration/Managing Care Awarded 96.0 points out of 96.0 possible points. 44. 44.ID: 22114994010 A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, what would be the first activity that the nurse would suggest to the task force? A. Teaching schoolchildren about the dangers of school violence B. Looking at what other communities are doing about school violence C. Distributing fliers that identify the causes of school violence to families in the community D. Conducting a community survey to assess community perceptions regarding school violence Correct members of the task force. Use the steps of the nursing process to answer the question. Eliminate the options that are implementation actions. To select from the remaining options, note the strategic word “assess” in the correct option. Review: assessment Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Awarded 96.0 points out of 96.0 possible points. 45. 45.ID: 22114994007 A nurse is planning care for her assigned clients. What does the nurse know about the purpose of the hospital’s standards of care? Select all that apply. A. Identify methods of treatment B. Evaluate current methods of treatment C. Provide direction for the practice of nursing Correct D. Provide competent care on the basis of current practice Correct E. Provide direction for care on the basis of the client’s diagnosis Incorrect F. Identify new care methods on the basis of current medical research Rationale: The purpose of standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, across the country. Standards of care include the provision of competent care on the basis of current practice. Methods of treatment are individualized to the care of a specific client. Providing direction of care on the basis of the client’s diagnosis is a matter of medical interventions. New care methods are a matter of research. Evaluate current methods of treatment are included in the standards of care purpose. Test-Taking Strategy: Focus on the subject, standards of care. Note the relationship of the subject and the information in the correct option. The correct option is also the umbrella option. Review: standards of care Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Awarded 0.0 points out of 96.0 possible points. 46. 46.ID: 22114994004 A registered nurse (RN) is supervising a nursing assistant ambulating a client with right- sided weakness. What observed activity by the nursing assistant would lead the RN to conclude that the nursing assistant is performing the procedure incorrectly? B. An unconscious client who requires oral care Correct C. A client who has just undergone cardiac catheterization D. A client who is getting up to ambulate for the first time after surgery Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. Oral care may be delegated to a nursing assistant. The nurse would provide instructions to the nursing assistant regarding the task, how to adapt the procedure for the client at risk for aspiration, and the signs/symptoms of complications that must be reported immediately (e.g., bleeding gums, excessive coughing). A client who has just undergone cardiac catheterization requires monitoring for complications, and a client scheduled for liver biopsy requires preparation for the test and client teaching. A client who is getting up to ambulate for the first time after surgery is at risk for orthostatic hypotension and should be assisted by a licensed nurse. Test-Taking Strategy: Focus on the subject, client the nurse should assign to a nursing assistant. Note that the question asks for the assignment to be delegated to the nursing assistant. When asked questions related to delegation, think about the role description of the employee and the needs of the client. For the nursing assistant, select the client who has needs that do not require a high skill level, meaning that assessment, teaching, and monitoring are not appropriate. Note that two of the incorrect options are comparable or alike in that they identify clients who have undergone invasive procedures. Review: delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care Awarded 96.0 points out of 96.0 possible points. 50. 50.ID: 22114995448 A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that he/she will not work the overtime if he/she has made other plans after his/her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? A. Ignoring the complaints B. Avoiding assigning the nurse mandatory overtime C. Confronting the nurse regarding his/her behavior regarding the overtime policy Correct Rationale: Confrontation is an important strategy for addressing resistance by a staff member who is complaining about an agency protocol. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings and identification of problems and issues, and give the nurse manager the opportunity to develop strategies to solve the problem. Ignoring the complaints and avoiding assigning the nurse mandatory overtime are inappropriate strategies that do not address the problem. Providing a positive reward system might provide a temporary solution to the resistance but will not specifically address the problem. Test-Taking Strategy: Note the strategic word “best” in the query of the question and focus on the subject, dealing with conflict. Eliminate the options that ignore the nurse’s complaints. To select from the remaining options, look for the option that specifically addresses the subject and provides problem- solving measures. Review: dealing with conflict Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management D. Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime Awarded 96.0 points out of 96.0 possible points. 51. 51.ID: 22114995445 A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (assistive personnel)? A. A client scheduled for a cardiac stress test B. A client who had a mastectomy 2 days ago C. A client scheduled for a laparoscopic cholecystectomy D. A client with renal calculi whose urine must be strained Correct Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. The nursing assistant has been trained to collect and strain urine. The nurse manager would provide instructions to the nursing assistant regarding the task, but the task is within the role description of a nursing assistant. A client scheduled for a cardiac stress test requires preparation for the test, teaching, and postprocedure monitoring. A client scheduled for surgery will require preoperative preparation, including teaching. A client who underwent mastectomy 2 days earlier will need both physiological and psychosocial care, requiring the skills of a licensed nurse. Test-Taking Strategy: Focus on the subject, client assigned to a nursing assistant. Rationale: The client with newly diagnosed leukemia who has a newborn at home is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making this the best and most appropriate assignment. To determine what may and may not be delegated to the various co-workers, the RN making the assignment must take into account several factors: the level of care required by each client, both immediately and in the future; the competencies possessed by the co-workers; and the legal limitations on the practice of those co-workers. Self-administration of insulin and discharge instructions on dressing changes and medications require teaching, a professional responsibility that the RN may not delegate to anyone except another RN. Although the RN might care for a client being discharged, the question tells you that an LPN is available. The RN would be best used to care for the client with more critical or complicated needs. Assigning an RN to a client who is being discharged with no medications is, therefore, incorrect. Test-Taking Strategy: Focus on the subject, best assignment by the RN. Use the process of elimination, noting the strategic word “best.” Eliminate the options in which the LPN is assigned to a client requiring teaching. To select from the remaining options, focus on each client and think about his or her actual and potential needs. The RN is best assigned to the client with physiological and psychosocial needs. employee and the needs of the client. For the nursing assistant, select the client who has needs that are noninvasive and do not require a high level skill, meaning that assessment, teaching, and monitoring are inappropriate tasks. Review: delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing CareAwarded 96.0 points out of 96.0 possible points. 52. 52.ID: 22114995442 A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. Correct B. The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man. C. The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin. D. The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications. living such as feeding him- or herself with the use of an adaptive device. Test-Taking Strategy: Focus on the subject, the need for assistance with insulin administration. Recalling the functions and roles of the home care nurse and the healthcare workers in the other options will help you answer correctly. Review: referrals Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Care Coordination HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing CareAwarded 96.0 points out of 96.0 possible points. 56. 56.ID: 22114995430 A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? A. Assisting a client with dysphagia in eating Correct B. Providing hygiene to a client with dementia C. Ambulating a client with Parkinson’s disease D. Assisting a client with an above-the-knee amputation in showering Rationale: In this case, the least appropriate assignment for a nursing assistant would be assisting a client with dysphagia with eating because of the risk of complications such as choking and aspiration. The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The remaining three situations include no data to indicate that these tasks carry any unforeseen risk. Test-Taking Strategy: Note the strategic words “least appropriate.” Use the ABCs — airway, breathing, and circulation — and recall the principles of delegation and supervision of tasks in answering the question. Remember, delegation of work must be consistent with the individual’s level of expertise and licensure or lack of licensure. Review: assignments and delegation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Health Care QualityAwarded 96.0 points out of 96.0 possible points. 57. 57.ID: 22114995427 A nurse is assigned to care for four clients. Which client should the nurse assess first? A. A client scheduled for a colonoscopy B. A client preparing for discharge after surgery Rationale: A client under contact precautions is the most appropriate assignment for the nursing assistant because the nursing assistant is trained to provide hygiene care and to care for clients under specific precautions. Assignment of tasks must be based on the job description of the nursing assistant, the assistant’s level of clinical competence, and state law. Blood transfusions, dressing changes, and ambulation of a client with angina require the skill of a licensed nurse. Test-Taking Strategy: Focus on the subject, assigning a client to the nursing assistant. Note the strategic words “most appropriate”. This indicates the best client to assign to the nursing assistant. Think about knowledge regarding tasks that may be safely delegated to the nursing assistant. Read each client description and think about the needs of the client. Recalling that clients requiring invasive procedures or close monitoring must be assigned to a licensed nurse will assist you in answering correctly. Review: delegation and assignment-making Rationale: Airway is always the priority, so the nurse would attend to the client who has a condition related to airway first. The other clients do not have conditions related to the airway and represent intermediate priorities. Test-Taking Strategy: Use the ABCs — airway, breathing, and circulation — to answer the question. The client with a tracheostomy is the only client with an airway problem. Note the strategic word “first”. Remember that airway is always the first priority. Review: prioritization Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, C. A client requiring a tube feeding through a gastrostomy tube D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask Correct Awarded 96.0 points out of 96.0 possible points. 58. 58.ID: 22114995424 A nurse is planning the client assignments for the shift. Which client is most appropriate for the nurse to assign to the nursing assistant? A. A client who needs a blood transfusion B. A client with diarrhea on whom contact precautions have been imposed Correct C. A client with angina who needs to be ambulated for the first time since admission D. A client with a draining abdominal wound that requires frequent dressing changes Rationale: The nurse should document task completion and client information throughout the day. Allowing time for unexpected tasks, prioritizing needs and tasks, and gathering supplies before beginning a task are all components of time management. Test-Taking Strategy: Note the strategic words “needs assistance.” These words indicate a negative event query and the need to select the incorrect action by the nursing graduate. Read each option carefully and recall the guidelines for time management to answer the question. Review: time management Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Health Care Quality HESI Concepts: Clinical Decision Malong-Clinical Judgment-Critical Thinking, Clinical Judgment, Adherence Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgemnt, Caregiving HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong- ClinicalJudgment-Critical thinkingAwarded 96.0 points out of 96.0 possible points. 59. 59.ID: 22114995421 A nurse is assisting a new nursing graduate with organizational skills in delivering client care. What action by the new nursing graduate suggests to the nurse that the new nursing graduate needs assistance with time management? A. Allows time for unexpected tasks B. Prioritizes client needs and daily tasks C. Gathers supplies before beginning a task D. Documents task completion and client information at the end of the day Correct Awarded 96.0 points out of 96.0 possible points. 60. 60.ID: 22114995418 A new nurse employed at a community hospital is reading the organization’s mission statement. What statements suggest that the new nurse understands what the organization’s mission is? Select all that apply. A. Describes the benefits available to employees B. Incorporates statements of philosophy (beliefs) Correct C. Outlines what the organization plans to accomplish Correct D. Includes the organization’s purpose,goals or objectives Correct E. Identifies the policies and procedures of the organization F. Defines the rules of the organization that the employees must follow Rationale: The policy or protocol for a client who has been raped will describe the physical, psychosocial, and legal responsibilities of the nurse. A policy or procedure is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online. Specific unit policies are sometimes referred to as protocols. Calling the nurse in charge during the day shift or asking an LPN or the police officers who brought the client into the ED is inappropriate. If the nurse needs additional information after reviewing the policy or protocol, it would be most appropriate to contact the agency nursing supervisor of the night shift. Test-Taking Strategy: Focus on the subject, care of a client who has been sexually assaulted. Use the process of elimination, recalling the legal implications related to providing care. Note that the incorrect options are comparable or alike in that they Rationale: Accountability, the process of answering or being responsible for what occurs, carries legal implications for task performance. Accountability cannot be delegated; one is responsible for one’s own actions and must answer for the care given, as well as for the care one asks others to complete. Test-Taking Strategy: Focus on the subject, the definition of accountability. Recalling this definition will easily direct you to the correct options. Review: accountability Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Professional Identity, Ethics HESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues- Ethics B. “You are responsible for your own actions.” Correct C. “It carries legal implications for task performance.” Correct D. “You are not responsible for the care that you ask others to complete.” E. “It refers to the process of answering or being responsible for what occurs.” Correct Awarded 96.0 points out of 96.0 possible points. 64. 64.ID: 22114993588 A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. What should the nurse do to determine the necessary actions in regard to this client’s injury? A. Ask a licensed practical nurse B. Call the nurse in charge of the day shift C. Ask the police officers who brought the client to the ED D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted Correct Rationale: Standards of care are authoritative statements that describe a common or acceptable level of client care or performance. They bear some similarity to policies and procedures. Therefore standards of care define professional practice. The American Nurses Association (ANA) has formulated general standards and guidelines for nursing practice. They are general in nature and apply across the nation. Test-Taking Strategy: Focus on the subject, standards of care formulated by the American Nurses Association. Note that the incorrect options are comparable or alike in that they contain the strategic words “specific”, “similarity” or “only.” Review: ANA standards of care Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Communication, Health Care Policy Review: organizational policies, procedures, or protocols Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Professional Identity, Leadership HESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues- EthicsAwarded 96.0 points out of 96.0 possible points. 65. 65.ID: 22114993585 A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. A. Are specific guidelines B. Define professional practice Correct C. Describe an acceptable level of client care Correct D. Have some similarity to policies and procedures Incorrect E. Are statements that relate only to the agency in which the nurse is employed F. Are authoritative statements that describe a common level of performance Correct Awarded 64.0 points out of 96.0 possible points. 66. 66.ID: 22114993582 In which situation is the nurse upholding the ethical principle of fidelity? A. Keeping promises made to clients. Correct B. Allowing a client to decide when to receive daily hygiene care C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion D. Providing complete information regarding treatment options to a client with newly diagnosed cancer E. Contacting the primary health care provider about the client’s request to incorporate complementary therapies for pain into the treatment plan Correct F. Providing complete information regarding treatment options to each client with a cancer diagnosis. Rationale: Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Contacting the primary health care provider about the client’s request that complementary therapies be used to relieve pain is an example of fidelity. Respect for a person’s autonomy, or independence, involves respecting that person’s right to determine his or her own course of action. Allowing a client to decide when he or she would like to have daily hygiene care is an example of respecting a client’s autonomy. Beneficence is taking action to help others. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion is an example of beneficence. Although insertion of an intravenous catheter might cause discomfort, the benefits of receiving the transfusion outweigh the temporary discomfort. Justice refers to fairness and equity; in the healthcare arena, this involves ensuring fair allocation of resources, such as nursing care, to all clients. Providing complete information regarding treatment options to each client with a cancer diagnosis is an example of justice. Test-Taking Strategy: Focus on the subject, definition of fidelity. Think about the definition of each item in the options. Note the relationship of the definition of fidelity and the correct options. Review: fidelity Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Leadership HESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues- Ethics Awarded 48.0 points out of 96.0 possible points. 67. 67.ID: 22114993579 Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? A. Encouraging a client who has had a stroke to consume thin liquids and foods B. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab C. Immediately picking up a dislodged radiation implant with to wear a mask. Airborne precautions require the use of a private room. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence- based practice. Recall the definition of evidence-based practice and recall that tuberculosis is transmitted by way of the airborne route. This will direct you to the correct option. Review: evidence-based practice Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Evidence, Health Care Quality Awarded 96.0 points out of 96.0 possible points. 69. 69.ID: 22114993573 A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? A. “I’m not working overtime today.” B. “You know how I hate to work overtime.” C. “I will if you need me, but I am not happy about this.” D. “I have plans after work and will not be able to work overtime.” Correct Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse responds aggressively by stating, “I'm not working overtime today” or “You know how I hate to work overtime.” The statement “I will if you need me, but I am not happy about this” is a passive-aggressive response. Test-Taking Strategy: Use the process of elimination, focusing on the subject, and note the strategic words “most assertive” response. Note the relationship between the data in the question and the correct option. Review: assertive communication Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Awarded 96.0 points out of 96.0 possible points. 70. 70.ID: 22114993570 A nurse manager arrives at work and is immediately faced with several activities that require attention. Which activity will the nurse manager attend to first? A. Stocking the medication closet B. Client assignments for the day Correct Rationale: The nurse manager must confront the nurse, discuss the behavior, and initiate problem-solving measures to ensure that the behavior does not continue. Taking extended lunch breaks is an unacceptable behavior, mainly because the behavior affects client care. Ignoring the situation, asking other staff members to cover for the nurse, and documenting the problem in the nurse’s personnel file are all inappropriate because none of these actions will resolve the problem. Test-Taking Strategy: Focus on the subject, dealing with staff member taking extended meal breaks. Note the stratgegic words “most appropriate”. This indicates the best way to deal with the situation. Remember your knowledge of the principles of dealing with conflict and unacceptable behavior and that it is most appropriate to confront and address a problem when it occurs. Also note that the incorrect options C. A phone message from a client’s wife D. A phone message from employee health services Rationale: The nurse manager must attend to client assignments first, because client care is the priority. Also, the nursing staff need their assignments so that they may begin client assessments and start delivering client care. The nurse manager should next check the medication supply to ensure that needed medications are available. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next return the phone calls. Test- Taking Strategy: Focus on the subject, activity the nurse manager attends to first. Note the strategic word “first” and and prioritization skills. Remember that the client is the priority. Eliminate the options that are not directly related to immediate client needs. This will direct you to the correct option. Review: time management Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 96.0 points out of 96.0 possible points. 71. 71.ID: 22114993567 A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is the most appropriate way for the nurse manager to deal with this situation? A. Ignoring the situation B. Asking other staff members to cover for the nurse C. Documenting the problem in the nurse’s personnel file D. Confronting the nurse to discuss the behavior and initiate problem- solving measures Correct Review: conflict Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Professional Identity, Communication HESI Concepts: Communication, Clinical Decision Making-Clinical Judgment- Critical ThinkingAwarded 96.0 points out of 96.0 possible points. 72. 72.ID: 22114993564 A primary health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients’ charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the primary health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? A. Fulfilling the physician’s request B. Discussing the situation with the nurse manager Correct C. Reporting the primary health care provider to the chief of medicine at the hospital D. Stating to the physician, “I don’t really care whether you report me. I am not writing your prescriptions.” Rationale: When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the physician’s request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the primary health care provider or seek assistance from the nursing supervisor. Fulfilling the physician’s request and writing the prescriptions in the clients’ charts ignores the issue. Reporting the primary health care provider to the chief of medicine is inappropriate, because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating, “I don’t care whether you report me. I am not writing your prescriptions” is an inappropriate statement and will result in further conflict between the nurse and physician. Test-Taking Strategy: Focus on the subject, dealing with conflict between a physician and staff member. First eliminate the option that ignores the subject. Next, eliminate the option that will result in further conflict between the nurse and physician. To select from the remaining options, think about the appropriate use of the organizational channels of communication; this will direct you to the correct option. Review: managing conflict Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Rationale: The most appropriate response by the nurse is to ask the surgeon and to visit the client in order to answer questions the client has about the surgery. Informed consent is the authorization by a client or a client’s legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client’s part, the nurse has the obligation to contact the surgeon. Telling the client that she needed to ask questions before signing the consent for surgery is incorrect. Although the client should be thoroughly informed before signing consent, the client has the right to ask questions thereafter. It is the surgeon’s responsibility to explain the procedure, and, if the client wishes, she has the right to cancel the surgical procedure. Although these are correct statements, they are not the most appropriate and do not address the client’s concerns. Additionally, they do not address the legal ramifications associated with informed consent. receiving a continuous infusion of intravenous therapy, or a client who requires frequent wound irrigation. Test-Taking Strategy: Focus on the subject, client not to be assigned to a pregnant nurse. Use the process of elimination, noting the strategic word “avoids.” This word indicates a negative event query and the need to select the client situation that could present a risk to a pregnant client. Thinking about the risks associated with each client listed in the options will direct you to the correct one. Review: sealed radiation implant Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 96.0 points out of 96.0 possible points. 76. 76.ID: 22114993552 A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? A. Telling the client that it is her surgeon’s responsibility to explain the procedure B. Contacting the surgeon and requesting that he/she visit the client to answer her questions Correct C. Informing the client that she has the right to cancel the surgical procedure if she wishes D. Telling the client that she needed to ask these questions before signing the informed consent for surgery appropriate”. This indicates the best response that the nurse can make. Recall that the primary health care provider is primarily responsible for explaining the surgical procedure to the client will direct you to the correct option. Review: informed consent Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Communication HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Awarded 96.0 oints out of 96.0 possible points. 77. 77.ID: 22114993549 A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? A. Call the client’s primary health care provider Incorrect B. Document the error in the client’s chart C. Report the nurse who changed the IV solution D. Ask the nurse whether he/she intends to report the error Correct Rationale: The first thing the nurse who observed the error should do is ask the nurse whether he/she intends to report the error. As means of helping ensure client safety, all errors must be reported to the physician, but this is not the initial action. The client also needs to be assessed immediately. An incident report should be completed by the nurse who discovered the error (the nurse who changed the intravenous solution). The appropriate documentation also must be made in the client’s record by the nurse who discovered the error. If the nurse who discovered the error indicates that the error will not be reported, it may be necessary for the other nurse to contact the supervisor. Test-Taking Strategy: Focus on the subject, nurse who observed a correction of IV therapy. Use the process of elimination, noting the strategic word “first.” This indicates the next action taken by the nurse who observed the error. Eliminate the options that are comparable or alike in that they involve reporting the error. To select from the remaining options, think about the principles of dealing with conflict. This will direct you to the direct option. Review: error in care Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Health Care Quality HESI Concepts: Professional Behaviors-Professionalism, Communication Awarded 0.0 points out of 96.0 possible points. 78. 78.ID: 22114993546 A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is “uncooperative and a real pain to care for.” What is the most appropriate way the nurse leader would manage this issue? A. Discourage the judgmental comments Correct B. Ignore the comments made about the client C. Report the nurses’ comments to administration D. Leave articles about judgmental opinions in the nurses’ report room Rationale: Discouraging judgmental comments is the most appropriate way for the nurse leader to manage this concern. Nurses must discuss clients in a professional manner and avoid using judgmental language such as “uncooperative” or “difficult.” When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not addressed. Leaving articles about judgmental opinions in the nurse’s report room indirectly addresses the issue. Additionally, the nurse manager cannot ensure that the nursing staff will read the articles. Likewise, reporting the nurses’ comments to administration does not directly address the issue. The best approach that the nurse manager can take is to directly discuss the issue with the staff members. This action is not identified in the options. Test-Taking Strategy: Focus on the subject, nurse leader dealing with judgmental comments made by staff. Note the strategic words “most appropriate”. This indicates the best way for the nurse leader to deal with the situation. Eliminate the options that are comparable or alike in that they do not directly address the staff’s unprofessional behavior. Review: judgmental comments Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Leadership HESI Concepts: Professional Behaviors-Professionalism, Communication Awarded 96.0 points out of 96.0 possible points. 79. 79.ID: 22114993543 A client receives cefazolin sodium by way of the intravenous route. During the infusion, the client begins exhibiting signs/symptoms of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. What does the nurse most accurately document? A. The client had an allergy to cefazolin sodium. B. The primary health care provider was notified because a rash developed while the client was receiving cefazolin sodium. C. The client is apparently allergic to cefazolin sodium, as indicated Rationale: The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. The affected client also complains that pain during passive motion is greater than that during active motion. The nurse must notify the primary health care provider immediately. The other options are incorrect because they delay necessary interventions. Test-Taking Strategy: Focus on the assessment data presented in the question. Note the strategic word first. This indicates the most important action to be taken by the nurse. Recall that these signs/symptoms indicate early acute compartment syndrome. Remember, if this is suspected, the primary health care provider needs to be notified. Also note that the incorrect options are comparable or alike in that they delay necessary intervention. Review: early acute compartment syndrome Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: aggressive action that does not address the conflict directly. Test-Taking Strategy: Focus on the subject, dealing with conflict. Refusing to perform the assignment is unethical and could be grounds for dismissal. Leaving the nursing unit constitutes client abandonment and could also result in dismissal. From the remaining options, select the option in which the conflict is dealt with directly. Note the strategic words “most appropriate”. This indicates the best way the nurse can deal with the situation. Review: dealing with conflict Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Collaboration HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Making- Clinical Judgment-Critical ThinkingAw rded 96.0 points out of 96.0 possible points. 81. 81.ID: 22114993537 A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. The nurse suspects early acute compartment syndrome. On the basis of these assessment findings, which action should the nurse take first? A. Contact the primary health care provider Correct B. Reassess the client in 30 minutes C. Check to see whether it is time for more pain medication D. Encourage the client to continue active range of motion exercises of the left arm Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions Awarded 96.0 points out of 96.0 possible points. 82. 82.ID: 22114993534 A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? A. Pulse B. Urine output C. Temperature D. Respiratory status Correct Rationale: Morphine sulfate depresses respiration, so the nurse must monitor the client’s respiratory status closely. Although the incorrect options may be components of the assessment, checking respiratory status is the priority nursing action. Test-Taking Strategy: Focus on the subject, assessment of a client receiving an IV infusion of Morphine sulfate. Use the process of elimination, noting the strategic word “first.” This indicates the priority action the nurse should take. Remember the ABCs — airway, breathing, and circulation — to guide you to the correct option. Review: continuous IV infusion of morphine sulfate Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Awarded 96.0 points out of 96.0 possible points. 83. 83.ID: 22114993531 A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. What should the nurse do first before administering the medication? A. Check the client’s apical pulse B. Check the placement of the tube Correct C. Check when the last feeding was given D. Check when the last medications were given Rationale: To help prevent aspiration, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Checking when a feeding or medication was last given and checking the client’s apical pulse are not directly related to the subject of the question. Test-Taking Strategy: Focus on the subject, priority action by the nurse before administering medications by way of an NG tube. Note the strategic word “first.” This indicates the priority action by the nurse. Use the ABCs — airway, breathing, and circulation. To help prevent the complication of aspiration when administering medications to a client with an NG tube, the nurse must first assess accurate Review: medications through an NG tube Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, AssessmentAwarded 96.0 points out of 96.0 possible points. 84. 84.ID: 22114993528 An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? A. Heart rate B. Radial pulse rate C. Peripheral pulses Correct D. Blood pressure (BP) Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered peripheral circulation. The first or priority assessment is for the nure to check the peripheral pulses to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the priority with a circumferential extremity burn is the assessment of peripheral pulses. Test-Taking Strategy: Focus on the subject, the nurse’s first assessment on a client with a circumferential burns to the extremities. Eliminate the options that are comparable or alike first (heart rate and radial pulse rate). To select from the remaining options, focus on the strategic words “first” and “circumferential burns of both legs.” Assessing peripheral pulses are the priority assessment in a client who has sustained a circumferential burn of an extremity. Review: bilateral circumferential burns of extremities. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ Assessment Content Area: Delegating/PrioritizingAwarded 96.0 poin s out of 96.0 possible points. 85. 85.ID: 22114993525 A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. What are the reasons for the nurse to review the chart? Select all that apply. A. Understand the organization’s reason for existence B. Be familiar with the organization’s line of authority C. Be familiar with the beliefs and values of the organizationIncorre ct Corre ct Rationale: Informed consent is a person’s agreement to allow something, such as a treatment, to be performed. A consent form is needed if the problem is a sexually transmitted infection. If the client is a minor, he or she may sign the informed consent in the following situations: if the client is an emancipated minor; if the client is seeking birth control services or is pregnant; if the client is seeking treatment for a sexually transmitted infection, drug or substance abuse, or psychiatric services; or if a court order or other legal authorization has been obtained. Test-Taking Strategy: Focus on the subject, a minor client seeking medical treatment for a sexually transmitted infection, Eliminate the options that are comparable or alike in that they indicate that the consent form must be signed by another individual. To select from the remaining options, recall that a consent form is required for treatment. Review: informed consent Rationale: The nurse would contact the primary health care provider and ask about the route of the medication. The medication prescription must include the medication name, dose, route of administration, time, and frequency of the administration. The nurse would not prepare the medication or administer it without first checking with the physician. A stat prescription must be administered immediately. Therefore, it is inappropriate to plan to have the nurse on the next shift administer the medication. Test-Taking Strategy: Focus on the subject, action by nurse to follow-up on incomplete prescription. Read the prescription and think about the procedure for fulfilling a prescription. This will reveal that the route of administration is not specified. Review: medication prescriptions Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Medication Administration Giddens Concepts: Clinical Judgment, Communication HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Awarded 96.0 oints out of 96.0 possible points. 89. 89.ID: 22114993513 A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, what does the nurse tell the client? A. She will need to sign an informed consent form Correct B. Her mother or father will need to be contacted for permission to treat her C. Anyone over the age of 18 years may sign a consent form for her treatment D. A consent form is not needed if the problem is a sexually transmitted infection Rationale: In an emergency situation, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save his or her life may be undertaken without informed consent. In such cases the law assumes that the client would wish to be treated. Contacting the hospital clergy to provide the informed consent and having the nurse sign on behalf of the client with another nurse to witness the signature are both incorrect. Also, having the client undergo mechanical ventilation until his parents can be contacted will delay treatment of a life-threatening injury. Test-Taking Strategy: Focus on the subject, informed consent for a client with a life- threatening injury. Note the strategic words “life-threatening injuries”. This will direct you to the correct option. Review: informed consent Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Health Care Law Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Communication, Health Care Law HESI Concepts: Communication, Teaching and Learning-Client Education Awarded 96.0 points out of 96.0 possible points. 90. 90.ID: 22114993510 An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client’s parents but is unsuccessful. What does the nurse do in regard to informed consent for the surgery? A. The nurse understands that consent is not needed Correct B. The nurse will contact the hospital clergy to provide informed consent C. The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature D. The nurse will prepare the client to undergo mechanical ventilation until the client’s parents can be contacted Awarded 96.0 points out of 96.0 possible points. 91. 91.ID: 22114993507 A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? A. Giving a verbal report to the nurse on the oncoming shift B. Checking neurological signs/symptoms in a client with a head injury C. Using clean gloves to change a gastrostomy tube dressing Correct Rationale: Using clean gloves is a negligent act. The nurse should use sterile gloves to change a dressing over broken skin. Common negligent acts include medication errors that result in injury to the client; intravenous therapy errors resulting in infiltrations or phlebitis; burns caused by equipment, bathing, or spills of hot liquids and foods; falls resulting in an injury; failure to use aseptic technique where required; failure to give report or giving an incomplete report to an oncoming shift; failure to adequately monitor a client’s condition; and failure to notify a primary health care provider of a significant change in a client’s condition. Test-Taking Strategy: Focus on the subject, the nurse not following sterile techniqe. Note the strategic words “negligent act”. This indicates a negative event query. Read each option carefully, and note the word “clean” in the correct option. Review: negligent acts Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Evidence, Health Disparities D. Contacting a primary health care provider about a change in a client’s blood pressure Awarded 96.0 points out of 96.0 possible points. 92. 92.ID: 22114993504 A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client’s record reflects the correct use of guidelines for documentation? A. The client seems anxious B. The client’s intake was 360 mL Correct C. The client’s wound is healing well D. The client is voiding large amounts Rationale: Quality documentation and reporting have five important characteristics: factual, accurate, complete, current, and organized. Using an accurate measurement of intake is correct. The use of the word “seems” indicates that the nurse did not know the facts. Using the word “well” is also incorrect, because it does not provide an accurate observation. Likewise, using the word “large” does not provide an accurate measurement. Test-Taking Strategy: Focus on the subject, proper guidelines for documentation. Recall the characteristics of quality documentation and reporting. Also note that the correct option is the only one that is specific. Review: documentation Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Communication and Documentation