Care Coordination And Transition Management

Fundamentals - Ethical/Legal

The nurse is observing staff members caring for assigned clients. The nurse should intervene if a staff member is observed

1. asking the spouse to make medical decisions on behalf of a client who is unconscious after a motor vehicle collision

2. restraining a client who is competent and requests to leave against medical advice

3. allowing a client who is competent to decline life sustaining treatment

4. securing a client’s personal belongings in a locked location

restraining a client who is competent and requests to leave against medical advice

Fundamentals - Medication Administration

The nurse is caring for a client who is refusing a scheduled dose of medication. Which of the following actions should the nurse take? SATA

1. complete an incident report

2. document the client’s refusal of the medication

3. ask a family member to encourage the client to take the medication

4. explore the client’s concerns and reasons for refusing the medication

5. explain the indications for the medication and the health consequences of refusing it

• document the client’s refusal of the medication

• explore the client’s concerns and reasons for refusing the medication

• explain the indications for the medication and the health consequences of refusing it

Leadership & Management - Assignment/Delegation

The nurse observes unlicensed assistive personnel (UAP) performing tasks for a client with heart failure. Which of the following actions by UAP would require the nurse to intervene? SATA

1. Helps the client get to the bathroom several times

2. instruct the client regarding prescribed fluid restriction

3. measures oxygen saturation and respiratory rate every 4 hours

4. positions the client upright in a chair after ambulation

5. records urine output on the intake and output flowsheet

instruct the client regarding prescribed fluid restriction

Mental Health - Mental Health Concepts

The nurse is assigning a task to the unlicensed assistive personnel (UAP). The UAP states, “This is too much! I am not going to help you.” Which of the following responses would be appropriate for the nurse to make?

1. “would you agree that difficult tasks are often good learning opportunities?”

2. “if this assignment concerns you, I will ask someone else to do it”

3. “In what way do you feel like this assignment is too much for you?”

4. “You should feel proud that I trust you with this assignment”

“In what way do you feel like this assignment is too much for you?”

Fundamentals - Ethical/Legal

The nurse is planning a staff education program about informed consent for minors. Which of the following scenarios could the nurse include as an example in which a minor may legally provide informed consent? SATA

1. admission to an inpatient mental health unit for suicidal ideation

2. participation in a research study for treatment of cystic fibrosis

3. surgical intervention for a ruptured ectopic pregnancy

4. administration of a scheduled varicella vaccine

5. treatment for alcohol withdrawal syndrome

• admission to an inpatient mental health unit for suicidal ideation

• surgical intervention for a ruptured ectopic pregnancy

• treatment for alcohol withdrawal syndrome

Mental Health - Mental Health Concepts

A nurse on the medical- surgical unit has been temporarily assigned to the Intensive Care Unit (ICU) and is speaking with the ICU nurse manager. Which of the following statements by the nurse would demonstrate assertive communication?

1. “I need to be assigned back to my unit for the shift. This is absurd”

2. “I have never worked in the ICU before, but I will accept the assignment”

3. “I am not sure who assigned me to this unit but that individual must not be competent”

4. “I feel uncomfortable accepting an assignment in the ICU. I would like to discuss other options”

I feel uncomfortable accepting an assignment in the ICU. I would like to discuss other options”

Fundamentals - Leadership & Management

The nurse is talking with a staff member about the role of the case manager. Which of the following information should the nurse include?

1. “The case manager provides clients with spiritual guidance after a family member has died.”

2. “The case manager assesses the medical, social, and psychological needs of clients”

3. “The case manager develops resolutions for ethical conflicts involving clients”

4. “The case manager creates specialty meal plans and diets for clients”

“The case manager assesses the medical, social, and psychological needs of clients”

Fundamentals - Safety/Infection Control

The nurse is planning a staff education program about falls. Which of the following information should the nurse include? SATA

1. “Opioid use increases the risk for client falls”

2. “Environmental hazards contribute to client falls”

3. “Clients with a history of falls are more likely to experience another fall”

4. “Restraint should be used to prevent falls for clients who are disoriented”

5. “Standardize fall risk assessments are not required for clients under age 65”

• “Opioid use increases the risk for client falls”

• “Environmental hazards contribute to client falls”

• “Clients with a history of falls are more likely to experience another fall”

Leadership & Management - Assignment/Delegation

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients in the emergency department. Which of the following clients would be appropriate for the nurse to assign to the UAP to obtain vital signs? SATA

1. the 5 YO client who has a suspected tibial fracture and is crying

2. the 17 YO client who was sexually assaulted and is emotionally withdrawn

3. the 29 YO client who is reporting flank pain during a blood transfusion

4. the 33 YO client who was admitted with suspected septic shock

5. the 82 YO client who has a suspected fractured hip sustained during a fall

• the 5 YO client who has a suspected tibial fracture and is crying

• the 17 YO client who was sexually assaulted and is emotionally withdrawn

• the 82 YO client who has a suspected fractured hip sustained during a fall

Leadership & Management - Ethical/ Legal

The nurse is caring for a client who was involved in a motor vehicle collision. The client becomes unresponsive and has no pulse. There is no advance directive in the medical record or family member present. Which of the following actions should the nurse take?

1. Activate the emergency response team and initiate CPR

2. Administer IV morphine and oxygen via nasal cannula to the client

3. call the client’s next of kin and ask if the client has executed an advance directive

4. Inform other staff members that the client should not be intubated or receive mechanical ventilation

Activate the emergency response team and initiate CPR

Leadership & Management - Management Concepts

The nurse is planning a staff education program about management of care. Which of the following information should the nurse include? SATA

1. “management of care involves the coordination of tasks to complete a goal”

2. “the nurse is responsible for coordinating home delivery of durable medical equipment”

3. “the nurse should act as a liaison between clients and the interdisciplinary team”

4. “evaluating the outcomes of interventions is an important part of the nursing process”

5. “accountability refers to taking responsibility for the actions of other”

• “management of care involves the coordination of tasks to complete a goal”

• “the nurse should act as a liaison between clients and the interdisciplinary team”

• “evaluating the outcomes of interventions is an important part of the nursing process”

Leadership & Management - Assignment/ Delegation

The nurse an unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to the UAP?

1. obtaining the daily weight for a client with heart failure

2. performing a dressing change for a client who had a laparotomy 4 hours ago

3. providing assistance during meals for a client who has dysphagia and facial droop

4. collecting a sterile urine specimen for a client who has an indwelling urinary catheter

obtaining the daily weight for a client with heart failure

Leadership & Management - Management Concepts

The nurse is admitting a client with HIV infection who is disoriented. Which of the following actions should the nurse take?

1. assign the client to a private room with monitored negative air pressure

2. place protective gowns outside the client’s room to be worn during client care

3. call the client’s sibling to review the past history and ensure that it is accurate

4. verify with the pharmacist that the client’s prescribed antiretroviral medications are available

verify with the pharmacist that the client’s prescribed antiretroviral medications are available

Fundamentals - Leadership & Management

The nurse has attended a staff education program about the role of case manager. Which of the following statements by the nurse would require follow up?

1. “The case manager is responsible for obtaining informed consent before surgery.”

2. “The case manager acts as a client advocate acts as a client advocate when communicating with health insurance providers”

3. “If a client decides to receive hospice care, the case manager can initiate the arrangements”

4. “If the health care provider orders speech therapy the case manager can help schedule client appointments”

“The case manager is responsible for obtaining informed consent before surgery.”

Mental Health - Mental Health Concepts

The nurse has attended a staff education program about the circular transactional model of communication. Which of the following statements by the nurse would indicate a correct understanding of the program?”

1. “communication feedback is given by 1 person”

2. “nonverbal communication is not a part of the model”

3. “information is sent and receive at different times”

4. “the communicator is both an encoder and a decoder of information”

“the communicator is both an encoder and a decoder of information”

Leadership & Management - Assignment/Delegation

The charge nurse is planning client care assignments for the next shift. Which of the following clients would be appropriate to assign to the licensed practical nurse (LPN)? SATA

1. the client who has diabetic ketoacidosis and is receiving IV insulin

2. the client who requires wound care and dressing changes every 4 hours

3. the client who is receiving enteral feedings and medications via a nasogastric tube

4. the client who has pneumonia and is receiving PO antibiotics and oxygen via nasal cannula

5. the client who is experiencing an acute exacerbation of asthma and requires oxygen therapy and nebulized medications

• the client who requires wound care and dressing changes every 4 hours

• the client who is receiving enteral feedings and medications via a nasogastric tube

• the client who has pneumonia and is receiving PO antibiotics and oxygen via nasal cannula

Leadership & management - assignment/delegation

The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease. Which of the following tasks are appropriate for the nurse to delegate to the unlicensed assistive personnel? SATA

1. checking the client’s sputum color and consistency

2. measuring the client’s fluid intake and output

3. recording the client’s oxygen saturation and respiratory rate

4. reviewing the steps for a peak flow meter examination with the client

5. verifying that the client is using an effective coughing technique

• measuring the client’s fluid intake and output

• recording the client’s oxygen saturation and respiratory rate

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Leadership & Management - Ethical/legal

The nurse is talking with a staff member in the lunchroom. The staff member asks, “Can you update me on the client I care for last week who had an acute stroke?” Which of the following responses would be appropriate for the nurse to make?

1. “I am not allowed to give you information regarding the client”

2. “The health care provider can update you on the client’s condition.”

3. “the client is doing well but has some residual effects from the stroke”

4. “You can access the client’s medical record when you return to the unit”

“I am not allowed to give you information regarding the client”

Mental Health - Mental health concepts

The nurse has attended a staff education program about nonverbal communication. Which of the following statements by the nurse would indicate a correct understanding of the program?

1. “body posture does not influence nonverbal communication”

2. “Nonverbal communication is not impacted by the pitch and rate of speech”

3. “Facial expression are a primary source of nonverbal communication”

4. “Verbal communication conveys more information than nonverbal communication”

“Facial expression are a primary source of nonverbal communication”

Leadership & Management - Ethical/ Legal

The nurse is talking with a health care provider via telephone. The health care provider states, “I noticed you are caring for a client I cared for during a previous admission. How is the client today?” Which of the following responses would be appropriate for the nurse to make?

1. “I will call you back when I am in a more private area”

2. “You have cared for the client before, so you can visit the client”

3. “The client is currently stable, which is an improvement from yesterday”

4. “I cannot talk to you about the client unless you are directly involved in the client’s care”

“I cannot talk to you about the client unless you are directly involved in the client’s care”

Leadership & Management - Management concepts

The nurse. is talking with a staff member about conflict resolution strategies. Which of the following statements by the staff member would require follow up?

1. “Smoothing occurs when a party attempts to appease another party”

2. “The avoiding approach occurs when parties are aware of the conflict but do not acknowledge it”

3. “Collaborating occurs when a party sacrifices its beliefs to allow another party to win”

4. “The competing approach occurs when a party works to achieve its desired outcome at the expense of others”

“Collaborating occurs when a party sacrifices its beliefs to allow another party to win”

Mental health - mental health concepts

The nurse is talking with the health care provider about a client’s plan of care. Which of the following actions by the nurse would demonstrate assertive communication? SATA

1. speaking in a soft tone with the HCP

2. avoiding hand movements while speaking

3. using “I” statements to communicate concerns

4. repeating thoughts and feelings as appropriate

5. nodding the head in acknowledgment while the HCP is speaking

• using “I” statements to communicate concerns

• repeating thoughts and feelings as appropriate

• nodding the head in acknowledgment while the HCP is speaking

Fundamentals - communication

The nurse on the mental health unit is talking with a client. Which of the following statements by the client would demonstrate a therapeutic nurse client relationship? SATA

1. “I need help managing my health conditions”

2. “I feel comfortable sharing my concerns with you”

3. “I plan to implement the interventions we developed together”

4. “I know I can trust you because you remind me of my grandmother”

5. “I would like to have personal telephone number in case I have any questions after I am discharged”

• “I need help managing my health conditions”

• “I feel comfortable sharing my concerns with you”

• “I plan to implement the interventions we developed together”

Fundamentals - leadership & management

The nurse is talking with a group of clients about the role of the case manager. Which of the following statements by a client would require follow up?

1. “The case manager will help obtain home assistive mobility devices”

2. “The case manager can coordinate long term care facility placement”

3. “The case manager can arrange outpatient occupational therapy”

4. “The case manager will prescribe my discharge medications”

“The case manager will prescribe my discharge medications”