DetailedAnswerKey-14 1. A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing a... ctions should the nurse take? 2. A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes? 3. A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? 4. A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? 5. A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? 6. A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? 7. A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) 8. A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take? 9. A nurse has completed an informed consent form with a client. The client then states, “I have changed my mind and do not want to have the procedure done.” Which of the following actions should the nurse take? 10. A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? 11. A nurse intercepts a messenger at the nurses’ station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, “I know Mrs. Welch from the neighborhood. What happened to her?” Which of the following responses should the nurse provide? 12. A nurse enters a client’s room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? 13.A A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? 14.A A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management? 15.A A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change? 16.A A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? 17. A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? 18.A A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? 19. A nurse manager is reviewing information about critical pathways with the unit nurses. Which of the following information should the nurse manager include? 20. A nurse on a pediatric unit is caring for four clients. The nurse should recommend an interdisciplinary client care conference for which of the following clients? 21.A A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? 22. A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take? 23.A A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? 24.A A community health nurse is reviewing information about infectious diseases with the nurses on her team. The nurse should remind the team that which of the following diseases are included in the list of nationally notifiable infectious diseases? (Select all that apply.) 25. A nurse is receiving a provider’s prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.) 26.A A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? 27. A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority? 28.A A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse’s priority? 29.A A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? 30.A A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? 31. A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) 32.A A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work, but are not exhibiting manifestation of illness. Which of the following is the appropriate action for the nurse to take? 33.A A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of the following agents should the nurse plan to administer a vaccine following exposure? 34.A A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? 35.A A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? 36.A A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? 37. A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) 38.A A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching? 39.A A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? . 40. While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? ..............................................................CONTINUED......................................................................... [Show More]
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