Kap Manag. B

the nurse manager talks with staff about conducting peer review for documentation of client care. which nurse will conduct a peer review of the staff nurse.

Another staff nurse on the unit

The nurse manager holds a staff meeting and discusses substance abuse among nurses. after the meetings, a staff nurse stays behind and asks to speak with the manager about a fellow staff member who could potentially be diverting. The nurse manager suspects this to be true when the staff nurse makes which statement.

The staff member frequently does not allow another nurse to visualize narcotics wasted, and states that the waste amount was appropriately disposed in the client's room.

an older adult client who is diagnosed with a terminal illness decides to go home with home hospice care. the client's adult child states, "you need to tell the health care provider that we want all possible treatments done.: the nurse states, your parent is competent and has the right to choose the treatment desired. the nurse's statement is based on which ethical concept.

Autonomy

The nurse on the pediatric unit receives the night shift's report and plans assignment for the day. which client doe the nurse see first?

The client diagnosed with hemophilia reporting joint pain.

four passengers in a motor vehicle accident are transported to the emergency department following an accident. the nurse triages in the emergency department. which client does the nurse see first.

an older adult with a head laceration who is drowsy and speaking incoherently.

The nursing team caring for clients on the pediatric unit consists of one nurse, two lpn/lvns, and three unlicensed assistive personnel. which client does the nurse assign to the UAP

the client who needs help socializing with other children

the nurse on the medical surgical unit talks with a client about an advance directive. which response by the client indicates the client understands the information.

When i complete my advance directive , i need to be sure there is a copy available to my health care provider and health care proxy.

the nurse receives the assignment for the day shift. which client is appropriate for the nurse to delegate to the lpn/lvn with 30 years of experience.

The adult client three days postoperative requiring a dressing change.

the nurse manager plans to conduct a performance appraisal of a nurse employed on the unit for the last year. to provide an accurate evaluation of the nurse's performance, which action by the nurse manager is most appropriate?

Enter anecdotal notes into the nurse's file periodically throughout the year.

The nurse received a report on 4 clients in the medical surgical unit. Based on the report received, which client does the nurse prioritize to see first?

The client diagnosed with heart failure who received 800 mL of IV fluid in 2 hours

The nurse plans to delegate tasks to the unlicensed assistive personnel. which task is within the UAP's scope of practice and appropriate for the nurse to delegate?

- obtain vital signs and document in the client's medical record.

- Assist the client with bathing and grooming

- appropriately document the client's I&O

Four clients in the emergency department are reporting adverse effects from medications. which client does the nurse see first?

The client receiving clozapine and experiencing flu-like symptoms.

the nurse is recently employed in a medical surgical unit at a medical center which has a clinical ladder system. The nurse understands which statement is accurate about a clinical ladder?

A clinical ladder provides a reward system for clinical excellence, with different responsibilities and advantages for each progressive level.

The nurse enters the room of a client admitted for evaluation of a convulsive disorder. the family members present report the client just had a seizure. after determining vital signs are normal and there are no injuries, then placing the client in side lying position, which action does the nurse take next?

interviews the family about what they observed, including the duration of the seizure, and accurately documents their responses using their own words.

The nurse reviews the client's history on the morning of surgery.

the nurse understand that the ability of a client to provide informed consent is based on

- Comprehension

- Legal capacity

_Voluntary action

CS: which finding prevents the client from providing informed consent SATA

- confused to location and time

- cannot follow simple instructions

For each observation below, click to specify the potential nursing intervention that would be appropriate for the care of the client. each observation supports 1 potential nursing intervention

- Surgeon enters room to discuss surgery: Observe and document the interaction with the client and family

- Eldest adult child leaves room to take a phone call: request the eldest adult child to wait to use phone

- surgeon examines client and asks if client has any questions: Remind surgeon client is unable to provide consent.

For each area of information the surgeon will provide, click to indicate if the information is required or not required for informed consent.

Required:

Expected results of the surgery

explanation of the procedure to be performed

Options to this course of action, including absence of treatment

Statement that the client/ family may withdraw consent at any time

Not required

Name of all personnel in the operating room

The surgeon leaves the room after explaining the procedure and the siblings begin to argue about whether or not the surgery should be performed.

- Notify the surgeon to speak with the family again

- Encourage the family members to verbalize their concerns

- Document the family members' questions and concerns

The surgeon returns and discusses the procedure with the clients family

- which statement demonstrates the family is prepared to provide informed consent for the procedure.

- i don't know if this is really going to help our parent , but we all agree we want to try

- We understand that there are no guarantees, but we agree this is the best thing to do

- Our oldest sibling has said we should proceed, and we have decided to let that sibling make the decisions.

The nurse is assigned to prioritize the care for clients in the psychiatric clinic. which client does the nurse see first?

The adolescent client who was brought in by the police threatening to jump off a bridge and has access to a gun

The nurse manager of a psychiatric day hospital is reviewing group theory as part of the orientation of new nursing staff who are going to develop and lead groups of clients. the manager identifies which group process stage as the one in which members are most likely to engage in arguments and power struggles.

Storming

The student nurse identifies characteristics of good documentation in a client's medical record. Which description adheres to the legal guidelines for appropriate documentation

The nurse documents any changes to the client's condition and any nursing actions taken response to the recorded changes.

a medical surgical unit uses the team nursing model of care to provide client care. which description most accurately describes team nursing?

The nurse leader is responsible for coordinating a group of licensed and unlicensed personnel to provide client care.

The nurse sees clients in the pediatric clinic. which client does the nurse see first

The 9-year-old client who used a weapon against the parents and caused physical harm.

The nurse educator provides information about negligence during a staff meeting. which example of negligence does the educator include

The nurse leaves the confused client alone on the bedside commode to take a phone call, resulting in injury to the client.

The nurse observes a student nurse give a presentation about incident reports. the nurse intervenes if the nursing student states which situation requires an incident report

The health care provider prescribes digoxin to be administered at 0900. the nurse administers the medication at 0920.

A client's spouse on the medical surgical unit states to the day shift nurse, my spouse was wakened all night long by the staff talking and laughing at the nurses station. I demand to speak to the chief nursing officer. which action by the nurse is most appropriate.

apologize to the client's spouse and report the situation to the nurse's immediate supervisor.

The community health maternity nurse plans visits for the day. which client does the nurse see first.

The newborn client with pallor

The nurse educator has just reviewed the concepts of group process roles with a group of nurse managers. one of the managers asks, could you please explain what exactly is meant by the gatekeeper role? which response by the educator is best

The gatekeeper ensures that everyone has an opportunity to speak