help 2

1. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for referral to speech-language pathology?

a. Altered level of consciousness - neuro

b. Diminished hand-to-mouth coordination

c. Impaired voluntary cough

d. Unilateral ptosis

c. Impaired voluntary cough - Speech therapist

1. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls? (Select all that apply.)

a. A raised vinyl seat on the toilet in the bathroom

b. A wheeled office chair at the client's computer desk

c. A folding chair without arm rests

d. A two-wheeled walker used to assist the client with ambulation

e. A throw rug covering some cracked vinyl flooring in the kitchen

b. A wheeled office chair at the client's computer desk

c. A folding chair without arm rests

e. A throw rug covering some cracked vinyl flooring in the kitchen

1. The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?

a. The oldest adult child

b. The client

c. The partner

d. The provider

b. The client

1. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

a. Contact the client's next of kin to obtain consent for treatment.

b. Notify risk management before initiating treatment.

c. Proceed with treatment without obtaining written consent.

d. Have the client sign a consent for treatment.

c. Proceed with treatment without obtaining written consent.

1. The charge nurse is evaluating a newly licensed nurse’s understanding of infection control procedures. Which of the following actions demonstrates that the nurse is following the appropriate protocol for a client to a streptococcal pharyngitis? (Droplet Precaution)

a. Wearing a mask when was in 1 m (3.3 ft) of the client.

b. Placing the client in a positive-airflow room with 12 air exchanges per hour.

c. Explaining to the client that he can have visitors until his manifestations resolve.

d. Donning sterile gloves when performing routine oral care.

a. Wearing a mask when was in 1 m (3.3 ft) of the client.

1. A nurse is comparing the rate of medication errors on the medical unit to the rate of a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using?

a. Risk benefit analysis

b. Root cause analysis

c. Benchmarking

d. Structure audit

c. Benchmarking

1. A nurse is preparing an education program about professional codes of ethics for nurses. Which of the following information should the nurse plan to include?

a. A code of ethics outlines the nurse's scope of practice.

b. A code of ethics is a step-by-step approach to decision making.

c. A code of ethics is a set of principles for nursing practice.

d. A code of ethics is legally binding.

c. A code of ethics is a set of principles for nursing practice.

1. A charge nurse witnesses an assistive personnel (AP) giving an oral medication to a client who has dysphagia. Upon questioning, the AP states that a nurse poured the medication into a cup and asked the AP to give it to the client. Which of the following actions should the charge nurse take first?

a. Auscultate the client's breath sounds.

b. Complete the appropriate documentation of the incident.

c. Reinforce faculty policy regarding medication administration with the AP.

d. Discuss the situation with the nurse who poured the medication.

a. Auscultate the client's breath sounds.

1. A nurse is evaluating care for a group of clients. The nurse should consult the provider for which of the following clients?

a. A client who requires an IV intermittent bolus dose of Vancomycin and has a creatinine level of 1.5 mg/dL. Normal 0.6 - 1.3 mg/dL

b. A client who has a pacemaker and whose cardiac monitor shows sinus rhythm with intermittent periods of a wide QRS complex after each pacer spike.

c. A client who is ready for discharge after coronary artery stent placement and has a prescription for clopidogrel.

d. A client who has atrial fibrillation and a rapid ventricular rate of 105/min and is receiving diltiazem IV and weight-based heparin. *105 bpm is normal for A fib

a. A client who requires an IV intermittent bolus dose of Vancomycin and has a creatinine level of 1.5 mg/dL. Normal 0.6 - 1.3 mg/dL

1. A nurse receives change-of-shift report for the following four clients. Which of the following clients or the nurse's assess first?

a. An older adult client who has bacterial pneumonia and a new onset of restlessness. Possible hypoxia

b. A client who is 1-day postoperative following hip fracture repair and reports a pain level of 6 on a scale from 0 to 10.

c. A middle adult client who has diabetes mellitus in the morning blood glucose of 172 mg/dL.

d. A client who has myasthenia gravis with ptosis and has developed urinary incontinence.

a. An older adult client who has bacterial pneumonia and a new onset of restlessness. Possible hypoxia

1. A nurse is discussing advance directives with a client. Which of the following statements by the client indicates an understanding of advance directives?

a. I know I have the right to determine if I remain on the breathing machine.

b. I trust my doctor, so I'm going to leave it to him to do what's best for me.

c. By naming a health care proxy, I give up the right to make my own medical decisions.

d. I know I'll need a lawyer to change them later, so I want to get them right.

a. I know I have the right to determine if I remain on the breathing machine.

1. A nurse tells the unit manager, "I am tired of all the changes on the unit. If things don't get better, I'm going to quit." Which of the following responses for the unit manager is appropriate?

a. I think you have a right to be upset. I am tired of the changes, too.

b. So you're upset about all the changes on the unit?

c. Just stick with it a little longer. Things will get better soon.

d. You should file a written complaint with the hospital administration.

b. So you're upset about all the changes on the unit?

1. A nurse manager is reviewing isolation by lines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

a. I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile. - wash with soap & water

b. I will wear a cover gown when caring for a client was herpes simplex.

c. I will place a client requires protective isolation in negative air-flow room.

d. I will wear n95 respirator mask when caring for a client who is on contact precautions. - airborne precaution

I will wear a cover gown when caring for a client was herpes simplex.

1. A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

a. Reorient the client to his surroundings.

b. Offer reassurance to the family.

c. Measure the client's vital signs.

d. Medicate the client with alprazolam.

a. Reorient the client to his surroundings.

1. A charge nurse is educating a group of newly licensed nurses about the case management approach to client care. Which of the following statements by a newly licensed nurse indicates an understanding of the responsibilities of a nurse in case management?

a. Nurses delegate and supervise assigned tasks.

b. Each nurse completes one specific task for a group of clients.

c. Nurses use critical pathways when caring for clients.

d. Nurses who have advanced training provide direct care for select clients.

c. Nurses use critical pathways when caring for clients.

1. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service?

a. A nurse can apply restraints on a PRN basis.

b. A nurse can administer medications without consent to a client as part of a research study.

c. A nurse can disclose information to a family member with the client's permission.

d. A nurse is responsible for informing clients about treatment options.

c. A nurse can disclose information to a family member with the client's permission.

1. A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first?

a. No transport assistance is available to take a client to physical therapy.

b. A client is refusing care from an assistive personnel of the opposite gender.

c. Two nurses had a heated disagreement about a scheduling issue.

d. Three staff members have called to say they will be absent.

b. A client is refusing care from an assistive personnel of the opposite gender.

1. A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first?

a. Notify the provider.

b. Complete an incident report.

c. Place a faulty equipment tag on the pump.

d. Auscultate the client's lungs.

d. Auscultate the client's lungs.

1. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first?

a. Remove the client's clothing.

b. Report the incidence to OSHA.

c. Irrigate the exposed area with water.

d. Don personal protective equipment.

d. Don personal protective equipment.

1. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include?

a. Regular programming evaluation can be conducted by telephone.

b. The client should avoid using remote control devices to prevent dysrhythmias.

c. The client should avoid using a microwave oven to heat food.

d. Swimming could cause the unit to have an electrical short.

a. Regular programming evaluation can be conducted by telephone.

1. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the following findings indicates the need for a referral to a wound care specialist?

a. Minimal signs of induration at the wound edges.

b. Presence of slough in the wound bed.

c. Epithelization noted in areas of tissue loss.

d. Presence of granulated tissue over the wound.

b. Presence of slough in the wound bed.

1. A charge nurse overhears a provider and a nurse talking about a client's diagnosis in the cafeteria. Which of the following actions should the nurse take first?

a. Remind them that client information is confidential.

b. Complete an incident report about the situation.

c. Report the incident to the nursing supervisor.

d. Discuss the need for client confidentiality at the next staff meeting.

a. Remind them that client information is confidential.

1. A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

a. Green

b. Black

c. Yellow

d. Red

b. Black

1. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures?

a. Prophylactic treatment should be initiated after a needlestick

b. An incident report should be completed if a client receives a stick from her own used needle.

c. The needle should be recapped to prevent injury during transport to the biohazard container.

d. I should stop the needle as soon as possible following a needlestick injury.

b. An incident report should be completed if a client receives a stick from her own used needle.

1. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried out the pain. Which of the following responses by the nurse is appropriate?

a. If you have the procedure now, you won't have to deal with pain and disability

b. Why didn't you discuss your concerns with your provider?

c. You'll be fine. You'll receive a prescription for a pain medication

d. I understand, and it's not too late to change your mind.

d. I understand, and it's not too late to change your mind.

1. A charge nurse is making assignments for a medical-surgical unit. Which of the following clients is appropriate to assign to a licensed practice nurse?

a. A client who has emphysema and has an oxygen saturation level of 92%

b. A client who is scheduled to start oral nutrition 2 days after a cerebrovascular accident

c. A client who is scheduled to receive 2 units of RBC's following a hip replacement

d. A client who has dehydration and is being admitted from the emergency department

a. A client who has emphysema and has an oxygen saturation level of 92%

1. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of interdisciplinary team should the nurse contact for assistance?

a. Occupational therapist

b. Physical therapist

c. Pharmacist

d. Respiratory therapist

b. Physical therapist

1. To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using?

a. Cooperating

b. Competing

c. Compromising

d. Collaborating

b. Competing

1. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?

a. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client

b. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better

c. A nurse gives prescribe opioids to a client who has a terminal illness and respirations of 8/min.

d. A nurse explains to a client's family that a DNR order includes withholding comfort measures

d. A nurse explains to a client's family that a DNR order includes withholding comfort measures

1. A nurse in the ED is preparing a married 17-year-old client for an appendectomy. The client's parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take?

a. Proceed with the preparation because the client signed a general consent form

b. Obtain consent from the client's parents by telephone with another nurse listening as a witness

c. Have the client sign the consent form after the surgeon explains the procedure

d. Delay the surgery until the parents arrive to sign the consent form

c. Have the client sign the consent form after the surgeon explains the procedure

1. A nurse is considering placing writ restraints on a client who has cognitive deficits and has pulled out his IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

a. Explain the procedure to the client and his family

b. Attempt less restrictive alternatives

c. Obtain a prescription for restraints from the provider

d. Document the indications for using wrist restraints

b. Attempt less restrictive alternatives

1. A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first?

a. Clarify competencies with the medical-surgical charge nurse

b. Refer to the assigned resource nurse regarding client assignments

c. Inform the nursing supervisor of the lack of experience on the medical-surgical unit

d. Request orientation to the medical-surgical unit

a. Clarify competencies with the medical-surgical charge nurse

1. A case manager observes a family member of a client who has Alzheimer's disease throwing boobs on the floor and sobbing while the client is having a diagnostic test. Which of the following actions should the case manager take first?

a. Refer the caregiver to a local group

b. Offer to have a brief talk with the caregiver

c. Consult social services to explore counseling

d. Help the caregiver arrange for respite care

b. Offer to have a brief talk with the caregiver

1. A nurse is planning discharge for a client who has a new diagnosis of COPD and lives alone. Which of the following actions is the nurse's priority?

a. Provide printed materials for the new prescriptions

b. Request a referral for a home safety assessment

c. Suggest participating in a community support group

d. Set up appointments for in-home physical therapy

b. Request a referral for a home safety assessment

1. A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate?

a. Elevating the head of the bed to a 20-degree angle

b. Flushing the tube with 15ml water

c. Adding colored food dye to the formula

d. Checking residual volume before each feeding

d. Checking residual volume before each feeding

1. A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

a. Using a pain rating scale to monitor a client's pain level

b. Instructing a client on self-administration of a tap water enema

c. Suctioning a client's long-term tracheostomy

d. Performing a dressing change on a client's peripherally inserted central catheter

c. Suctioning a client's long-term tracheostomy

1. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

a. Teaching a client to perform a finger-stick for testing blood glucose levels

b. Informing a family of a client's progress in physical therapy

c. Performing postmortem care prior to transferring the client to the morgue

d. Advising a client on a self-administration of acetaminophen

c. Performing postmortem care prior to transferring the client to the morgue

1. A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?

a. Notify the provider about he delayed oxygen tank delivery

b. Instruct eh client's family to contact the insurance provider about the oxygen equipment

c. Send an oxygen tank from the facility home with the client

d. Contact social services about the delivery of the oxygen equipment

d. Contact social services about the delivery of the oxygen equipment

1. A nurse is planning for four clients who were classified using a disaster triage tag system following a mass casualty event. Which of the following clients should the nurse identify as the priority?

a. A client who has a red tag

b. A client who has a green tag

c. A client who has a black tag

d. A client who has a yellow tag

a. A client who has a red tag

1. A nurse is providing discharge instructions to a client who is 2hr postoperative following cataract on the left-eye. Which of the following instructions should the nurse include in the teaching?

a. Place an ice pack on your left eye for 2 hrs after you get home

b. Remove your eye shield before going to bed

c. Sleep lying on your right side

d. Bend the waist if you must pick up an object from the floor – applies pressure to your eyes

c. Sleep lying on your right side

1. A nurse is caring for a client who is scheduled for a procedure. Which of the following is an appropriate action when the nurse is witnessing the client signing the consent form? (SATA)

a. Confirm the authenticity of the client’s signature

b. Discuss the benefit of the procedure with the client

c. Ensure the client gives consent voluntarily

d. Verify that the client affirms understanding of the procedure

e. Inform the client of available alternative therapies

a. Confirm the authenticity of the client's signature

c. Ensure the client gives consent voluntarily

d. Verify that the client affirms understanding of the procedure

1. A nurse is caring for a client who has early-stage Alzheimer’s disease. In which of the following actions is the nurse acting as a client advocate?

a. Reorienting the client several times throughout the day

b. Providing assistance for the client when ambulating down the hall

c. Requesting a referral for the client to attend reminiscent therapy sessions

d. Performing an updated cognitive assessment on the client

c. Requesting a referral for the client to attend reminiscent therapy sessions

1. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

a. The belief that the client has a difficult relationship with his son

b. The steps to follow when providing wound care

c. The client's preferred time for bathing

d. The time the client received his last dose of pain medication

1. A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel?

a. Updating a family member about a client’s condition

b. Reinforcing teaching with a client about a low-sodium diet

c. Demonstrating the use of an incentive spirometer to a client

d. Pouching a client’s established ostomy

d. Pouching a client's established ostomy

1. A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?

a. Keep the footplates lowered throughout the transfer process

b. Leave the transfer belt in place until the client returns from radiology

c. Push the wheelchair into the elevator, large wheels last

d. Test the locks on both wheels of the chair prior to transfer. - safety first

d. Test the locks on both wheels of the chair prior to transfer. - safety first

1. A nurse is planning discharge for a client following a hip arthroplasty. The client tells the nurse that she lives alone. Which of the following actions should the nurse take first?

a. Report the information to the provider.

b. Document the client’s living situation in the medical record.

c. Contact the case manager for a consultation. – social worker

d. Determine the specific needs of the client. - assess first

d. Determine the specific needs of the client. - assess first

1. nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

a. Human papillomavirus

b. Candidiasis

c. Gonorrhea

d. Trichomoniasis

c. Gonorrhea

1. A nurse is caring for a client who has signed consent for the removal of a tumor in the left frontal lobe of the brain. The client states, “The tumor is on the right side of my head.” Which of the following actions should the nurse take?

a. Continue with the surgery because the client already gave informed consent.

b. Ask the surgeon to clarify the operative site with the client.

c. Contact the surgery department to validate the operative site.

d. Tell the client to mark the right side of his head with indelible ink.

b. Ask the surgeon to clarify the operative site with the client.

1. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

a. Check on a client whose telemetry monitor is continuously beeping.

b. Instruct a client about the use of an incentive spirometer.

c. Tag a malfunctioning piece of equipment as broken.

d. Determine whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula.

c. Tag a malfunctioning piece of equipment as broken.

1. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

a. Child protective services

b. Social worker

c. Respiratory therapist

d. Pharmacist

b. Social worker

1. A nurse on a medical-surgical unit is preparing to assign vital sign measurements for a group of clients. Which of the following clients should the nurse delegate to an assistive personnel?

a. A client who has sickle-cell anemia and has completed an infusion of packed RBCs. – most stable

b. A client who has a closed head injury and increased intracranial pressure.

c. A client who has just returned to the unit from the PACU.

d. A client who reports acute chest pain.

c. A client who has just returned to the unit from the PACU.

1. A nurse is caring for a client who is comatose and has advance directives designating his adult daughter as his health care proxy. The client’s partner instructs the nurse to institute CPR if the client experiences cardiac arrest. Which of the following actions should the nurse take?

a. Contact the client’s attorney about the partner’s request.

b. Inform the partner that the staff must follow the client’s advance directives.

c. Have the partner notify the daughter about changes to the advance directives.

d. Initiate new advance directives incorporating the partner’s request.

a. Inform the partner that the staff must follow the client's advance directives.

1. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?

a. Store opened bottles of normal saline in a refrigerator for up to 48 hr.

b. Return unused supplies from the beside to the unit’s supply stock.

c. Wait to dispose of sharps containers until they are completely full.

d. Use clean gloves rather than sterile gloves for colostomy care.

d. Use clean gloves rather than sterile gloves for colostomy care.

1. A charge nurse is reviewing how to set up a sterile field with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the process?

a. I will open the outermost flap of the sterile tray towards my body.

b. I will keep the label of the solution bottle facing up when pouring solution into the sterile cup.

c. I will place the sterile tray on a bedside table that is raised to just below my waist level.

d. I can touch the outer 2 inches of the sterile field without gloves.

b. I will keep the label of the solution bottle facing up when pouring solution into the sterile cup.

1. A client is admitted with tuberculosis and placed in a negative-pressure room. Which of the following nursing actions is appropriate?

a. Ensure that admitting staff undergo PPD skin tests.

b. Place a sign on the client’s door with the diagnosis.

c. Determine who had contact with the client in the last 48 hr. – airborne precaution; fast spread

d. Notify the local health department of the admission.

c. Determine who had contact with the client in the last 48 hr. - airborne precaution; fast spread

1. A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene?

a. Points tubing in the direction of the umbilicus during insertion.

b. Inserts the tubing 8 cm (3.1 in) into the rectum.

c. Positions the client on her left side with knees flexed.

d. Administers the solution at room temperature. - may cause abdominal discomfort

c. Positions the client on her left side with knees flexed.

1. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred?

a. Negligence

b. Battery

c. Slander

d. Libel

a. Libel

1. A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

a. Tell the client to leave her purse in a drawer of the bedside table.

b. Offer to store the purse at the nurses' station.

c. Offer to place the purse in the facility safe.

d. Place the purse in the clothing bag with the client's other belongings.

c. Offer to place the purse in the facility safe.

1. A nurse manager is reviewing the nursing code of ethics with the staff nurse. Which of the following statements by a staff nurse indicate understanding of the teaching? (Select all that apply.)

a. I have the assistive personnel double-check packed RBCs when other nurses are busy.

b. I can delegate the removal of an IV catheter to an LPN on the unit.

c. I administer pain medication to my clients even if they have a history of narcotic addiction.

d. The family of a newly admitted client recently treated me to lunch in the hospital cafeteria.

e. I will attend continuing education classes for professional growth.

b. I can delegate the removal of an IV catheter to an LPN on the unit.

c. I administer pain medication to my clients even if they have a history of narcotic addiction.

e. I will attend continuing education classes for professional growth.

1. A charge nurse is completing client assignments. Which of the following assignments is appropriate for a licensed practical nurse?

a. A client who receiving IV chemotherapy.

b. A client who is 1 day postoperative and has a continuous bladder irrigation.

c. A client who requires discharge instructions for type 1 diabetes mellitus.

d. A client who requires a blood transfusion to be administered.

b. A client who is 1 day postoperative and has a continuous bladder irrigation.

1. A nurse is providing care for four postoperative clients. The nurse should first assess the client

a. Whose urine output has averaged 32 mL/hr for the past 24 hr.

b. Whose pulse has been steadily increasing during the past shift.

c. Who reports nausea after the prescribed antiemetic was administered.

d. Who reports a pain level of 8 on a scale of 0 to 10.

b. Whose pulse has been steadily increasing during the past shift.

1. A charge nurse making rounds observes that an assertive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

a. Inform the unit manager of the incident.

b. Speak with the AP about the incident.

c. Remove the restraints from the client’s wrists.

d. Review the chart for nonrestraint alternatives for agitation.

c. Remove the restraints from the client's wrists.

1. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr postoperatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery?

a. Pain assessment policy

b. Postoperative care policy

c. Retrospective chart audit -

d. Prospective chart audit

b. Postoperative care policy

1. A nurse is caring for a client and notices fraying on the electrical cord of the client's IV pump. Which of the following actions is the priority for the nurse to take?

a. Check the expiration date of the inspection sticker.

b. Remove the IV pump from the client's room.

c. Request a replacement IV pump.

d. Report the problem to the engineering team.

b. Remove the IV pump from the client's room.

1. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system?

a. Introduce the new scheduling system by describing how it will save the institution money.

b. Provide a brief overview of the new scheduling system immediately before its implementation.

c. Offer to reassign staff who do not support the change to another unit.

d. Identify nurses who accept the change to help influence other staff nurses.

b. Provide a brief overview of the new scheduling system immediately before its implementation.

1. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?

a. Provide coverage for the nurses' breaks.

b. Determine the reasons the nurses are not taking scheduled breaks.

c. Review facility policies for taking scheduled breaks.

d. Discuss time management strategies with the nurses.

b. Determine the reasons the nurses are not taking scheduled breaks.

1. A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation?

a. Document in incident report, "Entered room and discovered client lying prone on the floor."

b. Document in incident report, "Client found lying on the floor after failing out of bed."

c. Document in nurse's notes, "Incident report completed and filed."

d. Document in nurse's notes, "Photocopy of incident report sent to risk management."

a. Document in incident report, "Entered room and discovered client lying prone on the floor."

1. A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?

a. Nasal cannula and oxygen

b. Yankauer suction device

c. Bite block

d. Large-handled utensils

b. Yankauer suction device

1. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change?

a. Glasgow Coma Scale score

b. Reddened area on the coccyx

c. Laboratory tests scheduled for the next shift

d. Most recent blood glucose reading

a. Glasgow Coma Scale score

1. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?

a. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy.

b. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot.

c. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38 C (101 F).

d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void.

b. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot.