RN Leadership Online Practice 2023 B

Which of the following findings should the nurse identify require follow-up by the provider? Select 6 findings that require immediate follow-up?

HR

Bowel sounds

Urinary output

BP

Orientation status

O2 SAT

Pain lvl

RR

Dressing appearance

HR

BP

O2 SAT

Pain

RR

Dressing appearance

The nurse is reviewing the client's medical record. Which of the following findings should the nurse identify require immediate follow-up? Select 4 findings that require immediate follow-up

O2 SAT

Nausea

Weakness

BP

RR

Diaphoresis

ECG results

O2 SAT

BP

RR

ECG results

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired?

Frequent use of the restroom

A charge nurse is preparing to observe a newly licensed nurse to perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?

Place the client in a dorsal recumbent position for the examination

A nurse walks into the nurse's station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Remind the staff members that this a breach of confidentiality

A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?

Identify stable clients for transfer to a surgical unit

An assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make?

I delegate tasks to personnel based on their job descriptions

An occupational health nurse is triaging clients at the site of an industrial explosion. A class III, or green tag, should be assigned to the client with which of the following findings?

Facial contusions

A nurse is receiving a change-of-shift report. Which of the following clients should the nurse assess first?

A client who had abdominal surgery 6 hr ago and has had a HR of 120/min for the last 2hr.

A nurse in the ER is performing triage for a group of clients following a motor-vehicle crash (MVA). Which of the following clients should the nurse request the provider assess first?

A client who has arm contusions and manifests asymmetrical thoracic movement.

A nurse on a med-surg unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Receiving moderate sedation

A home health nurse is performing a home safety assessment for a family who has a toddler. Which of the following findings is a potential environmental hazard the nurse should discuss with the parents?

The toilet seat lid is in the raised position.

A nurse manager is reviewing the actions a staff nurse took when they observed smoke coming from a wastebasket in a client's room. The nurse manager should verify that the nurse acted appropriately when they performed which of the following actions first?

Transported the client to the hallway

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

Check the urinary output at 1100 for John Doe and report it to me immediately.

A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict?

I'm not sure whether I want to apply for the unit manager's position or start a family this year.

A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DNR) order. Which of the following statements by the AP indicates an understanding of the teaching?

I will call for the client's nurse to come to the room if I cannot detect the client's pulse.

A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality?

Tell a client's partner that the client's laboratory tests cannot be disclosed without permission

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Determine goals and objectives

A charge nurse is reviewing the plan of care for a client who has active herpes simplex lesions. Which of the following interventions is appropriate for the plan of care?

Wear a gown and gloves when caring for the client

A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to pollicy?

Report this issue to the nurse manager

A client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge?

Ensure that home infusion therapy has been arranged

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Review the AP's skill competency checklist

A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which of the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence?

Set a goal for improvement in adherence

A nurse is caring for a client who has an informed consent form for an upcoming procedure in their health record. Which of the following actions should the nurse take to validate that the client understands the procedure?

Ask the client to verbalize the purpose, risks, and benefits of the procedure

An RN is assigning tasks to team member. Which of the following tasks is appropriate to delegate to a licensed practical nurse (LPN)?

Suction a client who has a chronic tracheostomy

A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's priority?

Assign client care to staff

A nurse on a med-surg unit is planning care for a client who has dementia and is being admitted for surgery. Which of the following actions should the nurse take to promote client safety?

Place the client in a room near the nurse's station

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?

A nurse is photocopying their assigned client's diagnostic test results

A nurse in a mental health facility is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

I should request the provider to examine the client within 1hr of applying mechanical restraints

A clients on a general surgical unit tells a nurse that staff members are not answering the call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first?

Ask the client to verbalize their expectations

A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse?

A client who is 2 days post-op and has a urine output of 20mL/hr

A facility has identified an increase in health care-associated urinary tract infections (UTIs) on the med-surg unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process?

Establish best practice guidelines for reducing the incidence of UTIs

A nurse is caring for a 19-year-old client who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make?

I will gather information about palliative care for you.

A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?

This is a procedure that does not require written informed consent

A nurse manager is conducting an annual performance review for a staff nurse. Which of the following strategies should the nurse use in the review process?

Have the nurse conduct a self-appraisal prior to the review

Include peer evaluations completed by other staff nurses

Base the review on the nurse's performance during the past 90 days

Complete a performance checklist

Evaluate the nurse's performance based on a comparison of the nurse to others in the unit

Have the nurse conduct a self-appraisal prior to the review

Include peer evaluations completed by other staff nurses

Complete a performance checklist

A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?

Discuss the client's feelings about the procedure

A nurse receives a notification of a fire on the unit. Which of the following actions should the nurse take first?

Assist clients who are in immediate danger to a safe location

A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that they will not have the surgery. Which of the following actions should the nurse take?

Discuss the client's concerns about having the surgery

A client presents to an ER reporting back pain and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

Clients are the experts on their own pain

A nurse is caring for a school-age client who is seeking treatment for a laceration to the right forearm that occurred during soccer practice. The client was transported to the ER by a friend's parent and the soccer coach. The nurse should ensure that informed consent is given by which of the following people?

The client's guardian

A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take?

Review the client's request with the family

A nurse has 4 client assignments on a maternal newborn unit. Which of the following tasks can be delegated to an assistive personnel (AP)?

Measuring urine output of the client's first voiding

A nurse is caring for a client who is 3 days post-op following open heart surgery and will be transferred to the med-surg unit. Which of the following information should the nurse plan to include in the verbal report?

The client's level of consciousness (LOC)

A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?

A client who had a right above-the-knee (AKA) amputation 24 hr ago

A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take?

Assist in weighing the options involved in the decision

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

Provide an enteral feeding to a client who has Crohn's disease

A charge nurse is managing conflict with a staff nurse who does not agree with the client care assignment. Which of the following statements is an example of using the conflict resolution strategy known as smoothing?

You always complete your work on time and do a great job. I believe you can handle the assignment well.

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult when planning for this policy?

State Nurse Practice Act (NPA)

A nurse is caring for a client who has renal failure. The client tells the nurse that they have decided to stop hemodialysis treatment. Which of the following actions should the nurse take to act in the role of an advocate for the client?

Support the client's decision regarding treatment

Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should approach this conflict in which of the following ways?

Explore alternative solutions to address unit workflow with the nurses

A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I should complete an incident report for an unexpected client occurrence

A nurse is caring for a client who recently learned they have a mutation of the BRCA2 gene. The client states that they do not plan to tell their adult children about the diagnosis. Which of the following responses displays client advocacy by the nurse?

Let's review what you understand about this test result.

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client that the nurse should assess first?

The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.

A nurse is witnessing a client sign the consent form for a surgical procedure. The client has a question regarding alternative treatments. Which of the following actions should the nurse take?

Call the surgeon to discuss alternative treatments with the client

A nurse assumes care of a client following change-of-shift report. Which of the following actions should the nurse take?

Obtain a capillary blood glucose (CBG) reading

A nurse is reprimanded by a provider in front of a client. Which of the following actions should the nurse take to resolve the conflict?

Discuss the situation with the provider in private

The nurse is evaluating the client's plan of care. Which of the following findings indicate that the client's condition is worsening and the plan of care should be updated? SATA

Bowel sounds

Temp

HR

Sputum

O2 SAT

BP

RR

Temp

HR

Sputum

O2 SAT

RR

Select the employee findings that the nurse manager should identify as a concern for employee substance use disorder. SATA

Results of annual review

Change in social habits

Client statement

Charting

Mood changes

Hygiene

Attendance

Change in social habits

Client statement

Mood changes

Hygiene

Attendance

Select 1 action the nurse manager should take during the meeting between the 2 nurses to achieve a win-win resolution.

Encourage the nurses to collaborate with one another to address the conflict

The nurse is reviewing the client's plan of care. Which of the following findings require notification of the provider? SATA

Temp

Pain lvl

BP

HR

Prealbumin lvl

O2 SAT

Potassium (K+) lvl

WBC count

Temp

BP

HR

Prealbumin lvl

WBC count