HESI RN LEADERSHIP /MANAGEMENT EXIT EXAM 2024/2025 TEST BANK 120 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

Which actions of the nurse exhibit transactional leadership? Select all that apply.

1 Motivating or inspiring the employees

2 Meeting the targets within the deadline

3 Working according to organizational rules

4 Correcting the errors in a reactive manner

5 Increasing the employee commitment of an organization

2 Meeting the targets within the deadline

3 Working according to organizational rules

4 Correcting the errors in a reactive manner

The unit nurse manager comes to work obviously intoxicated. Which action is the staff nurse ethically obligated to take?

1 Call the security guard.

2 Tell the nurse manager to go home.

3 Have the supervisor validate the observation.

4 Offer the nurse manager a large cup of coffee

3 Have the supervisor validate the observation.

Which aspects are considered when determining the willingness of a nursing assistant before delegating a task? Select all that apply.

1 Ability

2 Attitude

3 Personality

4 Confidence

5 Commitment

2 Attitude

4 Confidence

5 Commitment

Which performance appraisal method is used by nurse managers to measure the performance of the nurse both qualitatively and quantitatively?

1 Narrative method

2 Critical incidents method

3 Graphic rating scale form

4 Behaviorally anchored rating scales

4 behaviorally anchored rating scales

The healthcare team is caring for clients in an emergency department. How soon should the clients triaged as an emergency severity index-3 (ESI-3) be seen by the physician according to the five level triage system?

1 Immediately

2 Within 1 hour

3 Could be delayed

4 Within 10 minutes

2 Within 1 hour

Which question does the registered nurse recognize as related to the right of circumstance when delegating?

1 "Is the delegation appropriate to the situation?"

2 "Is the task within the delegatee's scope of practice?"

3 "Is the prospective delegate a willing and able employee?"

4 "Is the delegator able to monitor and evaluate the client appropriately?"

1 "Is the delegation appropriate to the situation?"

Which factors does the registered nurse consider in the decision to delegate process? Select all that apply.

1 Evaluation

2 Nursing judgment

3 Predictability of outcomes

4 Pervasive functions of assessment

5 Complexity of the task to be performed

3, 5

Under a leader, a team of followers has failed to achieve success in conducting research. What does an effective leader do in this situation?

1 Criticizes the team members for failure

2 Provides excuses for the negative outcome

3 Refuses to take the responsibility for failure

4 Accepts failure and gains experience from it

4 Accepts failure and gains experience from it

The nursing manager wants to implement transformational leadership qualities. Which actions best describe this style of leadership? Select all that apply.

1 Providing intellectual stimulation

2 Intervening only when problems exist

3 Performing experiments with system redesign

4 Using motivator factors to inspire work performance

5 Monitoring performance and taking action to correct

1, 3, 4

Which component of delegation is defined as the ability to perform duties in a specific role?

1 Authority

2 Supervision

3 Responsibility

4 Accountability

1 Authority

The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel?

1 Administering antibiotics

2 Assisting with personal hygiene

3 Monitoring for signs and symptoms of infection

4 Teaching the client and caregivers about how to avoid infection

2

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?

1 Call the laboratory to repeat the test.

2 Take vital signs and notify the healthcare provider.

3 Inform the cardiac arrest team to place them on alert.

4 Take an electrocardiogram and have lidocaine available.

2

The nurse has accepted a position as a navigator. What should the nurse expect to learn during training for this role? Select all that apply.

1 Approaches to reduce the cost of health care

2 Learning ways to work through the health systems

3 Strategies to teach clients about disease, including prevention and treatment

4 Assessing barriers that clients have encountered while attempting to receive care

5 Helping clients cope with delays in receiving treatment until barriers are overcome

2, 3, 4, 5

What aspect of total client care needs to be taken into consideration if used on a 24-bed care area?

1 Cost of nurses

2 Training needs

3 Documentation

4 Time commitment

1 Cost of nurses

For which situations would total client care be an appropriate delivery system? Select all that apply.

1 Client scheduled for lithotripsy for renal calculi

2 Client with an endotracheal tube for pulmonary sepsis

3 Client recovering from cardiovascular bypass graft surgery

4 Client recovering from the placement of a cerebrospinal fluid shunt

5 Client transferring to a rehabilitation unit after total hip replacement surgery

2, 3, 4

Which intervention should the charge nurse perform to manage a task when the unlicensed nursing personal (UNP) is lacking competence?

1 Provide constructive feedback and assign another task.

2 Provide open vocal feedback and withdraw the UNP from task.

3 Provide additional support and temporarily lower expectations.

4 Provide accountability to the organization and undergo training again.

3 Provide additional support and temporarily lower expectations.

Which statement would most likely be made by a client who is receiving care through the functional method?

1 "My nurse's name is Amy."

2 "Susan will be caring for me until 7 pm."

3 "I have to wait until the medication nurse is available for a pain pill."

4 "Barbara coordinated all of my care but I might receive the care from other nurses."

3 "I have to wait until the medication nurse is available for a pain pill."

Which constructive aspects of conflict does the nurse leader identify? Select all that apply.

1 Polarizes groups

2 Releases pent-up emotions

3 Promotes ineffective communication

4 Helps individuals grow personally

5 Builds cohesiveness among people

2, 4, 5

When does delegation become more challenging? Select all that apply.

1 When the client is stable

2 When the client is pregnant

3 When the geographic area is small

4 When the resources are abundant

5 When school children are receiving care

2, 5

A client reports severe pain 2 days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

1 Encourage rest.

2 Obtain vital signs.

3 Administer the prescribed analgesic.

4 Document the client's pain response.

2 Obtain vital signs.

A nurse leader, along with the team, is caring for a client who is scheduled for colonoscopy. Which delegated task requires the leader's supervision?

1 Assisting the client with an enema

2 Assisting the client with bathing

3 Assisting the client with feeding

4 Assisting the client with ambulating

1 Assisting the client with an enema

Which comment by a team leader exemplifies team nursing the way it was intended?

1 "(Unlicensed assistive personnel), I need you to measure all vital signs."

2 "(Registered Nurse 1), check all of the intravenous (IV) sites and give the IV medications."

3 "(Licensed Practical Nurse), you pass all of the oral medications to the clients today."

4 "(Registered Nurse 2), Mr. Jones has a foot wound, two IV meds, and needs morning insulin."

2 "(Registered Nurse 1), check all of the intravenous (IV) sites and give the IV medications."

The registered nurse finds that two nursing students are arguing with each other. Which action by the registered nurse best represents a leadership quality?

1 Complaining to management and asking the students to go outside

2 Letting them continue arguing until they resolve the matter themselves

3 Assessing the condition and strategizing to resolve the matter by reducing the difference

4 Asking the reason for their argument and reprimanding them for having the argument in the hospital

3

Which point should the nurse exclude when developing strategies to project a powerful image?

1 Using authoritative language

2 Maintaining good body posture

3 Making good eye contact with clients

4 Ensuring that clothing and hair are appropriate to the situation

1 Using authoritative language

Which statement of the nurse leader reflects the actions suggested by the Joint Commission for disruptive behavior by a direct care nurse?

1 "This is the last warning for you."

2 "You are terminated, effective now."

3 "This will affect your assessment markings."

4 "You should not behave this way because you are very talented."

2 "You are terminated, effective now."

According to the three-tiered triage system, which client requires urgent treatment? Select all that apply.

1 A client with renal colic

2 A client with strains and sprains

3 A client with respiratory distress

4 A client with severe abdominal pain

5 A client with multiple displaced fractures

1, 4, 5

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation?

1 Measure other vital signs.

2 Stop administering the medication.

3 Elevate the head of the client's bed.

4 Report to the primary healthcare provider

2 Stop administering the medication.

A client is admitted to the emergency department following a motor vehicle accident. The client's wounds are extensive. Which healthcare team member is best suited to care for this client in the emergency ward?

1 Charge nurse

2 Registered nurse

3 Licensed practical nurse

4 Unlicensed nursing personnel

2 Registered nurse

A registered nurse (RN) delegates the task of foot care for a client to an unlicensed nursing personnel (UNP). The UNP is skillful and willing to perform the given task, but was recently hired and is unfamiliar with the client's condition. What should the RN do in this situation?

1 Provide guidance to the UNP.

2 Observe and motivate the UNP.

3 Establish mutual expectations and conditions.

4 Explain what to do and how to perform the task.

3 Establish mutual expectations and conditions.

Which characteristics of a licensed practical nurse should be considered before delegation of tasks? Select all that apply.

1 Critical thinking

2 Effective client care

3 Diagnostic reasoning

4 Synthesizing information

5 Accountability of assigned task

1, 3, 4

The registered nurse is caring for a client admitted to the hospital with chronic obstructive pulmonary disease. Which assessment by the registered nurse before delegating would help to determine the principle of "right person"?

1 "Is the environment conducive for completing the task safely?"

2 "Does the licensed practical nurse (LPN) know about polices of the institution?"

3 "Can the nursing assistive personnel (NAP) evaluate the client's' condition appropriately?"

4 "Does the nursing assistive personnel (NAP) have the knowledge and expertise to perform the task?"

4 "Does the nursing assistive personnel (NAP) have the knowledge and expertise to perform the task?"

The nurse delegates the tasks of caring for a postpartum client. During assessment, the nurse observes an infection in the client caused by lack of hygiene. Which member of the health care team is most likely responsible for the client's condition? Select all that apply.

1 Physician

2 Registered nurse

3 Licensed practical nurse

4 Licensed vocational nurse

5 Unlicensed assistive personnel

2, 5

Why does a nurse manager assign a resource person in a healthcare organization?

1 To delegate tasks

2 To supervise actions

3 To serve as a mentor

4 To reassign duties to workers

3 To serve as a mentor

A nurse is assisting another registered nurse in the intensive care unit who is caring for a client with uncontrolled blood pressure. Which action on the part of the nurse indicates "offering" during delegation decisions?

1 "Did you check the client's blood pressure this morning?"

2 "You can use this stethoscope and sphygmomanometer to take the blood pressure."

3 "Would you fetch me the client's laboratory reports? I'll record the blood pressure."

4 "How is the client doing this morning? Let me look at yesterday's blood pressure report."

2 "You can use this stethoscope and sphygmomanometer to take the blood pressure."

The nurse is caring for a pregnant client with hypertension. Which client care tasks are most suitable to be delegated to the patient care associate (PCA)?

1 Recording the vital signs

2 Monitoring the blood pressure

3 Administering intravenous fluids

4 Administering antihypertensive medications

1 Recording the vital signs

The registered nurse assigns a task to a newly hired licensed practical nurse (LPN) to monitor a client's blood pressure. Which is relevant to the delegator in this situation?

1 Requires explanation

2 Requires little guidance

3 Requires more guidance

4 Requires creating mutual expectations

3 Requires more guidance

The registered nurse is evaluating the statements made by a student nurse after teaching about the delegation communication template. Which statement made by the student nurse indicates a need for correction?

1 "The delegation communication template should identify the priorities."

2 "The delegation communication template should specify the deviations."

3 "The delegation communication template should identify the appropriate resources."

4 "The delegation communication template should include only the work that is to be delegated."

4 "The delegation communication template should include only the work that is to be delegated."

The registered nurse is assessing the conditions of four different clients. Which client's care should the registered nurse delegate to an unlicensed assistive personnel (UAP)?

1 Client A - brain injury; acute care

2 Client B - diarrhea; sub-acute care

3 Client C - uncontrolled DM; chronic care

4 Client D - HTN; acute care

2 Client B - diarrhea; sub-acute care

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse?

1 Ability

2 Liability

3 Stability

4 Ethnicity

3 Stability

The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client?

1 Certified technician

2 Case manager

3 Cross-trained technician

4 Licensed vocational nurse (LVN)

4 Licensed vocational nurse (LVN)

The licensed practical nurses (LPN) are most suitable to be delegated the task of reinforcement teaching.

A certified technician is an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A case manager can provide primary education to the client. These personnel can delegate the task of reinforcement teaching to the assistive nursing personnel. Cross-trained technicians may perform respiratory therapy, draw blood samples, and monitor electrocardiography.

The charge nurse is assigning client care to oncoming staff. The new nurse on the unit expresses an inability to care for the assigned client and is requesting to be reassigned. What should the delegator do in this situation?

1 Provide little guidance to the delegatee

2 Evaluate the ability and willingness of the delegate.

3 Understand the delegatee's motivation in the situation.

4 Understand the kind of support needed to accomplish the task.

3 Understand the delegatee's motivation in the situation.

An inability to care for the assigned client shows inability and/or unwillingness in the new nurse. The delegator needs to understand the delegatee's motivation related to the situation and should use selling leadership style, which leads to a supportive relationship.

Little guidance should be provided to the delegatee when he or she has high ability and willingness to perform the task delegated efficiently. When a new team begins to work together, the delegator should evaluate the ability and willingness of the delegatee. In the application of practice before delegation, the delegator needs to understand the kind of support to be given to accomplish the task.

Who acts as a delegator in the absence of the registered nurse?

1 Charge nurse

2 Patient care associate

3 Licensed practical nurse

4 Unlicensed nursing personnel

1 Charge nurse

The charge nurses act as a delegator on the basis of knowledge and experience in clinical settings. In the absence of a registered nurse, the charge nurse usually delegates the tasks.

A patient care associate assists and monitors vital signs. Licensed practical nurses and unlicensed nursing personnel are considered delegatees due to insufficient experience and training.

The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the client's current condition. Which characteristic of communication has interfered with the delegation process?

1 Information decay

2 Information salience

3 Confidence in abilities

4 Synergy between team members

1 Information decay

Information decay can occur in a rapidly changing situation when reported information is no longer relevant to a client's condition.

Information salience describes the different ways individuals from different backgrounds might assess the quality, meaning, and clarity of certain information. Trust is developed when there is confidence in the abilities and capabilities of the team members. Healthy relationships among members of the health care team promote synergy between the team members.

The registered nurse (RN) and unlicensed assistive personnel (UAP) have been working together for two years. Which statement made by the RN would be appropriate after delegating a task to the UAP?

1 "Let me tell you how to do this task."

2 "You know what to do and when to report."

3 "Please tell me how you are going to perform this procedure."

4 "It is important that you check the client's temperature every hour."

2 "You know what to do and when to report."

According to Hersey's model of situational leadership, the delegator should act according to the situation. When there is an established relationship between the delegator and the delegatee, little guidance needs to be provided to the delegatee.

When the relationship is new and a new task is delegated, an explanation is required about how to perform the task. When the delegatee is newly assigned, then the delegator checks the ability of the delegatee by asking how to perform the procedure. When the relationship between the delegatee and delegator is new, and it is for a limited period, then the delegator just informs the delegatee what is to be done.

The registered nurse (RN) is caring for a client with renal calculi. Which healthcare professional is most suitable to be delegated the task of administering urinary alkalinizer by mouth to the client?

1 Certified technician

2 Patient care associate

3 Licensed practical nurse

4 Unlicensed assistive personnel

3 Licensed practical nurse

Administering oral medications such as urinary alkalinizer can be safely delegated to a licensed practical nurse (LPN) or licensed vocational nurse (LVN) as per guidelines.

Certified technician is a licensed assistive personnel whose scope of practice is limited for administering medications. The scope of practice of the patient care associate and unlicensed assistive personnel is limited to performing basic care, feeding, and hygiene.

Which client's care is least likely to be delegated to unlicensed nursing personnel (UNP)?

1 Client A - paraplegia, home care

2 Client B - femur fracture in cast, extended care

3 Client C - Alzheimer's, long-term care

4 Client D - accidental poisoning, emergency care

4 Client D - accidental poisoning, emergency care

UNP can safely care for clients in stable condition because these cases will not require critical nursing assessment and decision-making. In an emergency setting, the client with accidental poisoning should be kept under constant monitoring and any small detail of fluctuation should be noted. Therefore, client D cannot be safely delegated to UNP. Clients undergoing home care, extended care, or long-term care do not require exhaustive monitoring and do not have life-threatening conditions, so they can be safely delegated to UNP.

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

1 Bradypnea

2 Bradycardia

3 Hypotension

4 Hypothermia

4 Hypothermia

After the removal of the burn client's clothing, the priority for the nurse is to monitor for hypothermia because burn trauma clients lose their ability to maintain body temperature due to the loss of skin which acts as an insulator. While the nurse will monitor for bradypnea, bradycardia, and hypotension, hypothermia is the priority.

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care?

1 Avoiding manipulation of the client's limbs

2 Asking a family member about any client drug allergies

3 Cutting fabric that is stuck to the client's skin with scissors

4 Auscultating heart and lung sounds through the client's clothing

3 Cutting fabric that is stuck to the client's skin with scissors

The nurse should remove all clothing to allow for a thorough assessment of the trauma client in order to accurately prioritize care. Cutting fabric that is stuck to the client's skin with scissors is the appropriate action by the nurse.

It is necessary to avoid manipulation of the client's limbs during the trauma assessment. While it is important to ask a family member about any client drug allergies, this is done after the initial assessment of the client. Clothing is always removed to allow for an accurate trauma assessment.

The nurse is teaching a client how to teach the supraglottic method of swallowing. Arrange the prioritizing order of statements by the nurse for teaching the client.

1. "Swallow twice."

2. "Hold your breath."

3. "Clear your throat."

4. "Take a deep breath."

5. "Place yourself in an upright position."

6. "Place a half to 1 teaspoon of food into your mouth."

1."Place yourself in an upright position."

2."Clear your throat."

3."Take a deep breath."

4."Place a half to 1 teaspoon of food into your mouth."

5."Hold your breath."

6."Swallow twice."

The order of steps to be followed in instructing the client in the supraglottic method of swallowing is first to place the client in an upright position, secondly to tell the client to clear the throat, and then to take a deep breath. The fourth step is for the client to place a half or one teaspoon of food into the mouth. The client should hold his or her breath and then swallow twice. This method exaggerates the normal protective mechanisms with cessation of respiration during the swallow.

Which order of steps would the nurse teach the client to follow while performing expansion breathing?

1. Place hands on each side of lower ribcage, just above the waist.

2. Sit in an upright position with knees slightly bent.

3. Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs.

4. Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation.

1.Sit in an upright position with knees slightly bent.

2.Place hands on each side of lower ribcage, just above the waist.

3.Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation.

4.Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority?

1 Place the client in a left side-lying position.

2 Apply oxygen via nonrebreather mask.

3 Apply a petroleum gauze dressing over the site.

4 Prepare to reinsert a new chest tube.

3 Apply a petroleum gauze dressing over the site.

A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment.

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action?

1 Change the dressing.

2 Reinforce the dressing.

3 Replace the tape with Montgomery ties.

4 Support the incision with an abdominal binder.

2 Reinforce the dressing.

The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.

Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply.

1 Collaboration

2 Care planning

3 Communication

4 Clinical judgment

5 Cultural competency

1, 4, 5

Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply.

1 Airway

2 Disability

3 Breathing

4 Circulation

5 Cervical spine

1, 5

The charge nurse is identifying tasks for staff caring for clients using functional nursing. Which tasks should be assigned to the licensed practical/licensed vocational nurse (LPN/LVN)? Select all that apply.

1 Showering two clients after breakfast

2 Administering topical and oral medications

3 Providing discharge instructions to three clients

4 Measuring capillary blood glucose level for five clients

5 Identifying nursing diagnoses after analyzing collected data

2, 4

The case manager notes that a client's hospitalization is being prolonged for one day because of an unexpected adverse medication reaction. What action should the case manager take?

1 Add the extra day into the pathway.

2 Document the reaction as a variance.

3 Change all uses of the pathway to add the extra day.

4 Prepare documentation to submit to Medicare about the extra day.

2 Document the reaction as a variance.

If a client's progress deviates from the normal path, a variance is indicated. A variance is anything that occurs to alter the client's progress through the normal critical path. The reason(s) for the variance should be analyzed and the care revised to meet the needs of the clients.

An extra day is not added into the pathway and all uses of the pathway are not changed by adding an extra day based on this single variance. There is no evidence to support that the case manager needs to submit documentation to Medicare about the extra day.

Which skills are essential for the nurse who is setting priorities for client care? Select all that apply.

1 Evaluation

2 Assessment

3 Critical thinking

4 Case management

5 Clinical decision-making

2, 3, 5

The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client?

1. Use direct pressure for external bleeding.

2. Prepare for chest decompression if needed.

3. Assess breath sounds and respiratory effort.

4. Establish airway by positioning, suctioning, and oxygen as needed.

5. Maintain vascular access using a large-bore catheter.

1.Establish airway by positioning, suctioning, and oxygen as needed.

2.Assess breath sounds and respiratory effort.

3.Prepare for chest decompression if needed.

4.Maintain vascular access using a large-bore catheter.

5.Use direct pressure for external bleeding.

The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.

What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)?

1 Teaching the client to report blurred vision

2 Teaching the client to report signs of infection

3 Teaching the client to report shortness of breath

4 Teaching the client to report stomach discomfort

1 Teaching the client to report blurred vision

Plaquenil is a hydroxychloroquine used to treat rheumatoid arthritis. The adverse effect of Plaquenil is retinal damage; therefore, a client on Plaquenil is taught to report blurred vision.

A client on steroids is taught to report signs of infection. A client on infliximab is taught to report shortness of breath. Plaquenil causes mild stomach discomfort, which is normal and is not related to priority nursing care.

A case manager telephones a client with lung disease to evaluate respiratory function with home oxygen use and then contacts the primary care provider. What is the purpose of this communication?

1 Collect data

2 Plan activities

3 Validate interventions

4 Evaluate expected outcomes

4 Evaluate expected outcomes

It is essential that the case manager have frequent interaction with the client and the healthcare provider to achieve and evaluate expected outcomes. The nurse is not phoning the client and care provider to collect data, plan activities, or validate interventions.

Which statement describes the practice partnership model of care delivery?

1 Nurse and unlicensed assistive personnel work the same shifts and days.

2 Nurse provides unlicensed assistive personnel (UAP) report for a group of clients.

3 Unlicensed assistive personnel (UAP) perform the same task for a group of clients.

4 Unlicensed assistive personnel (UAP) measure vital signs and provide morning care.

1 Nurse and unlicensed assistive personnel work the same shifts and days.

In the practice partnership model of providing client care, a registered nurse (RN) is paired with a technical assistant who works with the RN consistently, which means they are scheduled to work the same shifts and days. The nurse providing a report for a group of clients would be an action within team nursing. Unlicensed assistive personnel (UAP) performing the same task for a group of clients would be seen in functional nursing. Unlicensed assistive personnel (UAP) measuring vital signs and performing morning care would be a part of team or functional nursing. In the practice partnership model, the nurse and UAP would measure vital signs and perform care together.

Which actions indicate that a manager is helping staff adjust to functional nursing? Select all that apply.

1 Staff meeting conducted every Tuesday at 1 pm

2 Charge nurse assigned to analyze client outcomes

3 Staff assigned to make out daily assignments sheet

4 Assigned tasks rotated among same category of care providers

5 Staff nurses assigned to review research studies for evidence-based care

1, 4

The nurse is assisting a client out of bed. Which is the priority nursing action?

1 Monitoring the client's blood pressure

2 Assessing the client's level of consciousness

3 Ensuring the call bell is within the client's reach

4 Assisting the client from a supine to an upright position

4 Assisting the client from a supine to an upright position

The priority action to ensure the client's safety when assisting a client during a transfer is to assist the client from a supine to an upright position.

Monitoring blood pressure and assessing the level of consciousness nursing actions that should be completed prior to assisting the client out of bed. Ensuring the call bell is within the client's reach is a nursing action that should be completed each time the nurse leaves the client's room.

A hospital management team has conducted a randomized controlled trial to decrease the occurrence of ventilator-associated pneumonia. The trial was successful and had positive outcomes. The nurse manager, in collaboration with other hospital management staff, conducted the same trial in another hospital, but the results were different. Which research strategy implementation would the nurse manager consider to be beneficial in preventing dramatic differences in trial results?

1 Evidence-based practice (EBP)

2 Practice-based evidence (PBE)

3 Client-centered outcomes research

4 Comparative effectiveness research (CER)

2 Practice-based evidence (PBE)

PBE is a research methodology that helps inform practice. It uses an observational cohort study design that compares clinically relevant interventions, includes diverse study participants, uses heterogeneous practice settings, collects data on a broad range of health outcomes, and includes frontline clinicians in study development.

EBP is the integration of the best research evidence with clinical expertise and the client's unique values and circumstances in making decisions about the care of individual clients.

Client-centered outcomes researchers conduct research to provide information about the best available evidence to help clients and their providers make decisions that are more informed.

CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods.

A nurse leader is teaching about the functional model of nursing to a student nurse. Which statements made by the student nurse indicate effective learning? Select all that apply.

1 "I will focus on one nurse caring for one client."

2 "I will accentuate the use of team collaborations."

3 "I will focus on tasks and activities allotted to me."

4 "I will provide comprehensive and coordinated nursing service."

5 "I will coordinate the unlicensed personnel to provide care to a large group of clients."

3, 5

The nurse leader noticed that the staff nurse recently promoted to the surgical unit is lacking confidence at work and is worried about a pending review by the nursing director. Which source of power is applicable in this situation?

1 Reward power

2 Coercive power

3 Referent power

4 Connection power

2 Coercive power

Coercive power stems from a real or perceived fear of another person.

Reward power is perceived as being able to provide rewards or favors. Association with a powerful person grants referent power. Association with people who are powerful or who have links to powerful people gains connection power.

The nurse as a leader assists multidisciplinary leaders to achieve optimal functioning to benefit client care delivery. Which Gardner's task is the nurse applying?

1 Managing

2 Developing trust

3 Serving as a symbol

4 Achieving workable unity

4 Achieving workable unity

When the nurse assists multidisciplinary leaders to achieve optimal functioning to benefit client care delivery, it indicates the Gardner's task of achieving workable unity. Relating to and inspiring staff, management, and community leaders to achieve desired levels of health and well-being indicates Gardner's task of managing. When the nurse is honest in role performance, it indicates Gardner's task of developing trust. When the nurse represents the values and beliefs of the organization to internal and external constituents, it indicates Gardner's task of serving as a symbol.

Which responsibility of the nurse manager differs from the responsibilities of a nurse leader?

1 Planning the budget

2 Motivating the team

3 Resolving the conflicts

4 Penalizing for poor performance

1 Planning the budget

Budgeting is the responsibility of a nurse manager. The role of nurse leader is to motivate the nursing subordinates. Resolving conflicts is the responsibility of both the nurse leader and the nurse manager. Penalizing for poor performance is a behavior of transactional leadership.

The chief operating officer (COO) discusses the performance of a newly appointed leader with the nursing staff. The team communicates that the practical approach of the leader fulfills the quantum theory. What type of work environment does the COO understand that the leader creates at the workplace?

1 An environment that promotes hygienic factors

2 An environment that is rapidly changing and dynamic

3 An environment that provides intellectual stimulation

4 An environment that develops trust between followers and leaders

2 An environment that is rapidly changing and dynamic

"Quantum theory" lays its foundation on an environment that is rapidly changing. It does not focus on a single event.

Hygienic factors in the environment are an aspect of the two-factor theory. The nurse leader, through the transformational theory, provides intellectual stimulation. An environment that develops trust between followers and leaders are aspects of the situational-contingency theory.

The nurse leader actively participates in the quality improvement process. Arrange the steps in a sequence that the nurse leader will follow while implementing the quality improvement process?

1. Select a plan to meet the outcomes.

2. Collect the data for evaluating the plan.

3. Establish the outcomes and quality indicators.

4. Identify the important needs of the consumer.

5. Collect the data on the current status of the service.

6. Collaborate with the interprofessional team to review needs.

1. Identify the important needs of the consumer.

2. Collaborate with the interprofessional team to review needs.

3. Collect the data on the current status of the service.

4. Establish the outcomes and quality indicators.

5. Select a plan to meet the outcomes.

6. Collect the data for evaluating the plan.

The registered nurse (RN) is teaching a student nurse about the qualities of a transactional leader. Which statement made by the student indicates effective learning?

1 "I will penalize team members for poor performance."

2 "I will motivate employees by articulating an inspirational vision."

3 "I will encourage employees to transcend their own self-interests."

4 "I will challenge the process that involves new solutions to old problems."

1 "I will penalize team members for poor performance."

A transactional leader is responsible for penalizing a nurse executive for poor performance. This type of leader influences followers to fulfill their contracts or get penalized.

Motivating employees by articulating an inspirational vision is the behavior of a transformational leader. Encouraging employees to transcend their own self-interests to increase job satisfaction is the behavior of a transformational leader. Challenging the process that involves new solutions to old problems is the behavior of a transformational leader.

A nurse manager proposes to change a protocol regarding the care of postoperative clients. However, the nursing staff openly expresses their resistance to the change and wants to continue with the original protocol. Which behavioral pattern in response to change best describes the nursing staff?

1 Laggards

2 Rejectors

3 Early majority

4 Late majority

1

Laggards value their traditional practices and may openly express their resistance to the change.

Rejectors actively resist the change and may use sabotage to avoid the change. An early majority may prefer a conventional approach but accept the change gradually. A late majority is openly resistant to change and does not accept the change until all others have accepted it.

Which task followed by the executive nurse is a leadership development task?

1 Maintaining balance

2 Having a clear vision

3 Listening to constituents

4 Maintaining a positive attitude

1

Having a clear vision and seeing beyond where one is and where one is going is a leadership development task.

Maintaining balance, listening to constituents, and maintaining a positive attitude are rules for a leader.

Which critical factors would the nurse say are associated with situational-contingency theory? Select all that apply.

1 Environmental demands

2 The personal characteristics of followers

3 The ability of the leader to reward followers

4 The degree of trust and respect between leaders and followers

5 The task structure about goals and the complexity of the problems being faced

3, 4, 5

Which action of the nurse leader indicates implementing Gardner's task of "explaining"?

1 Assisting clients and families in formulating their vision of future well-being

2 Providing self-care to enhance the ability to care for staff, clients, and their families

3 Teaching and interpreting the information to ensure clients' functioning and well-being

4 Assisting clients in sorting out and articulating personal values in relation to health problems

3 Teaching and interpreting the information to ensure clients' functioning and well-being

The nurse leader implements Gardner's task of "explaining" by teaching and interpreting the information that ensures clients' functioning and well-being.

The nurse leader implements Gardner's task of "envisioning goals" by assisting clients and their families in formulating their vision of future well-being. The nurse leader implements Gardner's task of "renewing" by providing self-care to enhance the ability to care for staff, clients, and their families. The nurse leader implements Gardner's task of "affirming values" by assisting clients and their families as they sort out and articulate personal values in relation to health problems.

Which behavior of the nurse indicates management skills according to Gardner's task of achieving workable unity?

1 Assisting the client/family with planning, priority setting, and decision making

2 Assisting multidisciplinary leaders to achieve optimal functioning to benefit client care delivery

3 Assisting clients to achieve optimal functioning to benefit the transition to enhanced health functions

4 Assisting staff to achieve optimal functioning to benefit the transition to enhanced organizational functions

4 Assisting staff to achieve optimal functioning to benefit the transition to enhanced organizational functions

According to Gardner's task of achieving workable unity, the nurse in a management position helps the staff achieve optimal functioning to benefit transition to enhanced organizational functions. Assisting the client/family with planning, priority setting, and decision making is the clinical position of Gardner's task of managing. Assisting multidisciplinary leaders to achieve optimal functioning to benefit client care delivery is the executive position of Gardner's task of achieving workable unity. Assisting clients to achieve optimal functioning to benefit the transition to enhanced health functions is the clinical position of Gardner's task of achieving workable unity.

The nurse manager is looking to include members of the health care team in the decision-making process but finds that many members are reluctant to offer ideas. Which approach by the manager generates a large volume of creative options while encouraging reticent members of the team to participate?

1 Applying the Delphi technique

2 Organizing focus groups

3 Planning brainstorming sessions

4 Applying nominal group techniques

3

Brainstorming helps to get a large volume of creative options from the team by providing a safe environment for the contribution of ideas.

The application of the Delphi technique, focus groups strategy, and nominal group techniques are also effective in minimizing these problems, but do not provide a large volume of creative options. The Delphi technique involves collection and summarization of opinions and judgments on a particular issue from expert panels through interviews, surveys, or questionnaires. A focus group involves organizing moderated discussions with small groups of people to identify problems or evaluate processes; it is less likely to provide a nonjudgmental environment for generating ideas. A nominal group technique allows the opportunity to the team members to share ideas, but their ideas are judged and merits are given to each idea.

A client with myocardial infarction is admitted in the emergency department, and the primary health care provider recommended the placement of a stent. The client is incompetent to understand the situation. What model does the nurse manager think would be beneficial in this situation?

1 Decision model

2 Autonomy model

3 Social justice model

4 Patient-benefit model

4 Patient-benefit model

The patient-benefit model uses substituted judgment such as determining what the client would want for himself or herself if capable of making these issues known, and thereby facilitates decision making for incompetent clients.

The decision model is used for nurses; it depends on specific circumstances to know if the situation is routine and predictable or complex and uncertain. The autonomy model facilitates decision making for competent clients. The social justice model considers broad social issues and is accountable to the overall institution.

Which type of behavior by the registered nurse results in a low-to-stable level of commitment?

1 Punitive

2 Charismatic

3 Inspirational

4 Intellectual stimulation

1

Punitive behavior is a type of transactional leadership behavior that results in a low-to-stable level of commitment as an organizational outcome.

Charismatic, inspirational, and intellectual stimulation are transformational leadership behaviors that result in increased commitment as an organizational outcome.

The leader encounters a situation where the nursing outcomes are unpredictable. Which attributes or approaches should the leader utilize to navigate this situation? Select all that apply.

1 Creativity

2 Experience

3 Enthusiasm

4 Group process

5 Independent decision making

1 Creativity, 2 Experience, 4 Group process

The nurse manager orders the direct care nurse to assist in providing tertiary care to a client. Which type of treatment would the direct care nurse be involved in?

1 Chronic care

2 Rehabilitation

3 Health maintenance

4 Prevention of disease complications

2

Tertiary care includes rehabilitation.

Chronic care and health maintenance are considered primary care, and prevention of disease complications is classified as secondary care.

The nurse leader arranges a meeting with the staff members to learn how satisfied they are with their jobs. Which approach by the nurse leader would outline effective leadership? Select all that apply.

1 Seeking feedback from the team

2 Allotting work schedules to the team

3 Penalizing the team for poor performance

4 Motivating the team to reach the desired goals

5 Asking the team to participate in decision making

1, 4, 5

During a peer review, the manager finds that a newly appointed nurse leader encourages "bottom up" interaction among the workers. To which statement of the staff does the manager relate this?

1 "He/she accepts responsibility willingly."

2 "He/she is empathetic to the experiences of others."

3 "He/she involves us in shaping policies for client care."

4 "He/she believes in unleashing constructive energy rather than constraining energy."

3 "He/she involves us in shaping policies for client care."

"Bottom-up" interaction values every nurse as a human resource with rich perspective. Therefore involving peers in shaping policies is an example of a "bottom-up" interaction.

Willingness to accept responsibility is a generally desired attribute. Empathy to others' experiences shows emotional intelligence. A leader who unleashes constructive energy demonstrates the concept of focus on emergence.

The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation?

1 Leadership

2 Delegation

3 Supervision

4 Assignment

2

Delegation is the concept of a transfer of authority between two people to perform some type of task, e.g., between an RN and licensed staff.

Leadership is the action of leading a group or an organization. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance. Assignment is the transfer of both accountability and responsibility.

A healthcare team is caring for a client with diabetes insipidus. According to the functional model, which healthcare personnel would the nurse state is qualified to perform all hygienic tasks?

1 Registered nurse

2 Licensed practical nurse

3 Licensed vocational nurse

4 Unlicensed assistive personnel

4 Unlicensed assistive personnel

Unlicensed assistive personnel perform all the hygiene tasks. Per the functional model, intravenous (IV) medication administration is provided by the registered nurse. The licensed practical nurse and a licensed vocational nurse may be permitted to give IV administration of medications, but they maybe limited to giving oral medications.

The registered nurse is teaching a newly hired nurse about communicating with delegatees during delegation. Which statement made by the newly hired nurse indicates the need for further learning?

1 "I should identify priorities."

2 "I should specify deviations."

3 "I should provide examples of each delegation."

4 "I should specify any performance limitations to the delegatee."

3 "I should provide examples of each delegation."

The delegator should ask the delegatee to provide examples of each delegation in order to understand his or her knowledge level. The delegator should identify priorities before delegating the task to the delegatee. The delegator should specify deviations, such as when the delegatee must take an immediate action while performing the task. The delegator should specify the performance limitations to the delegatee, which can help in performing the task effectively.

Before assigning a task, the registered nurse makes sure that the prospective delegatee is willing to complete the task. Which delegation right does this situation reference?

1 Person

2 Supervision

3 Circumstance

4 Communication

1 Person

Ensuring that the prospective delegatee is willing to complete the task refers to the delegation right person. Knowing whether the delegator is able to monitor and evaluate the client appropriately refers to the delegation right supervision. Ensuring whether the equipment and resources are available to complete the delegation process refers to circumstance. Ensuring whether the delegator and delegatee understand a common work-related language refers to the delegation right communication.

A registered nurse (RN) is sent to a rehabilitation center because of chemical impairment issues. Which member of the healthcare team will be asked to provide feedback about the RN's progress?

1 Nurse manager

2 Healthcare provider

3 Patient care associate

4 Cross-trained technician

1

The nurse manager, who is the delegator for the healthcare team, will be asked to provide feedback about the progress of the RN in the rehabilitation center. The healthcare provider will not be asked to provide feedback about the RN's progress. The patient care associate and cross-trained technician also do not provide feedback about the RN because they do not supervise the RN.

After caring for a client who underwent a cesarean section, the delegatee failed to report results and findings of vital signs to the delegator due to improper understanding. Which action of the delegator is the reason for the delegatee's failure?

1 Unclear directions to the delegatee

2 Inappropriate selection of delegatee

3 Inappropriate feedback related to task

4 Inappropriate supervision by the delegator

1

Unclear directions to the delegatee by the delegator may result in failure to report results and findings of vitals by the delegatee. As per the rights of delegation, the delegator may not assign the task to an inappropriate delegatee. Inappropriate feedback related to the task may be due to an information delay that may cause adverse effects in the client. Inappropriate supervision by the delegator may lead to unexpected outcomes.

What factors are most important for the nurse to consider when delegating responsibilities?

1 Preferences of the clients and staff

2 Physical layout of the unit and client rooms

3 Staff member's level of education and expertise

4 Client's diagnosis and length of time in the hospital

3

Delegation should provide for client safety based on staff capabilities as determined by level of education and experience. Although client and staff preferences may be considered, they are not the most important criteria for determining delegation of tasks. Although geographic factors may be considered when tasks are delegated, these are not the most significant criteria to consider. The client's acuity, not diagnosis or length of time in the hospital, is the most important client factor to consider when appropriate staff members are assigned to provide care.

While delegating a task, the registered nurse says to the delegatee, "Please tell me how you go about performing this procedure, and I will share with you my perspective about how frequently and under what conditions we need to communicate with and report to each other." What does this indicate?

1 The delegatee requires explanation.

2 The delegatee has limited knowledge.

3 The delegatee and delegator relationship is established.

4 The delegatee and delegator are creating mutual expectations.

4 The delegatee and delegator are creating mutual expectations.

Asking a delegatee how he or she performs the procedure and sharing each other's perspective and when to communicate indicates that the delegator and delegatee are creating mutual expectations.

When the delegatee demonstrates a task, it indicates that the delegatee requires explanation. The delegator will direct the procedures to the delegatee when the delegatee has limited knowledge. The delegator will motivate the delegatee when the relationship between the delegatee and delegator is established.

Which statement about the delegatee condition is true regarding "selling"?

1 The delegatee has established relationships and expertise.

2 The delegatee has ongoing relationships; however, the task is new.

3 The delegatee has limited knowledge and ability to perform the task.

4 The delegatee has willingness and ability, but the relationship is new.

2

"Selling" in context with delegation represents an ongoing relationship with a new task being delegated.

"Participating" in the context of delegation includes willingness and ability to perform a task with a new relationship. "Telling" in the context of delegation includes limited knowledge and ability to perform the task by the delegatee. "Delegating" in context with delegation represents established relationships and expertise.

Which healthcare professionals would the nurse say work under active delegation? Select all that apply.

1 Physician examining clients in the outpatient ward

2 Nurse giving medication to a client as prescribed by the physician

3 Pharmacist dispensing medicines prescribed by the physician to the client

4 Licensed practical nurse (LPN) administering oral medications as delegated by the registered nurse (RN)

5 Unlicensed nursing practitioner (UNP) maintaining oral hygiene of the clients as delegated by the registered nurse

4, 5

The nurse notifies the health care provider of a change in client condition. Which of the following reports given by the nurse includes the most appropriate and complete information?

1. "A 43-year-old client with pneumonia in room 343 has wheezing, crackles, and diminished breath sounds. Temperature is 101.2 F (38.4 C), respirations are 36/min, and pulse oximeter shows 90%. I think the client may need arterial blood gas testing."

2. "A 75-year-old client in room 474 is in respiratory distress. The respiratory therapist (RT) gave a breathing treatment, but the client is deteriorating rapidly. The RT did not hear left side breath sounds and recommends a chest x-ray."

3. "An 80-year-old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen

3

The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for communicating information about a change in client status to the health care provider (HCP). It includes the following information:

S = Situation - what prompted the communication

B = Background - pertinent information, relevant history, vital signs

A = Assessment - the nurse's assessment of the situation

R = Recommendation - request for prescription or action from the HCP

The report given by the nurse in Option 3 contains the most appropriate and complete information. The nurse includes pertinent data related to history, admission, and present treatment (background); indicates when and what changes occurred (situation, assessment); and requests a prescription from the HCP (recommendation).

(Option 1) This report does not include any information indicating a time frame for admission or when the change in condition occurred.

(Option 2) This report does not include any information related to the admission time frame, current diagnosis, or pertinent data assessed by the nurse giving the report.

(Option 4) This report does not include any information related to the admission time frame or pertinent data assessed by the nurse giving the report.

Educational objective: Nurses commonly use the SBAR framework to report changes in client status to the health care provider, communicating the current situation, client background, nurse's assessment, and a recommendation for prescription or action.

The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time?

1. Call the answering service and speak to the health care provider now

2. Document the results of the culture in the client's medical record

3. Leave a message on the health care provider's office phone

4. Speak to the health care provider on rounds in the morning

1

Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1).

(Option 2) The critical laboratory result should be documented in the client's medical record, but only after immediate communication with the HCP.

(Option 3) The nurse must make direct contact, either via telephone or in person, when reporting a critical result. A telephone message may not be received promptly, and a critical value requires immediate intervention.

(Option 4) Even if the HCP usually makes rounds early in the morning, a critical value requires immediate, real-time notification to prevent delay of potentially urgent intervention.

Educational objective: Critical laboratory results, such as positive blood cultures, require immediate communication with the health care provider (HCP) and timely intervention for client safety. The nurse must contact the HCP directly as soon as possible to avoid life-threatening complications (eg, septic shock).

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response?

1. "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems."

2. "I will talk with the HCP about your concerns, but in the meantime it's important that you stay here."

3. "It's important that you stay in the hospital so that we can treat you quickly if you have problems."

4. "You have the right to make your own decisions, but you are at high risk of having heart problems if you go h

1

When clients are hospitalized, they lose control of many things, including their medication management. This loss of control can be frightening for the client, especially one who has had control of medications for many years.

This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed.

Care planning should be a collaborative, shared process informed by the knowledge and preferences of the client and evidence-based recommendations by the HCP that are appropriate to the situation.

(Option 2) This response is based on the idea of the nurse and HCP being in control, but it fails to include the client in the decision-making team.

(Option 3) This statement provides a rationale for the client to remain in the hospital, but it does not address the client's concerns about going into withdrawal.

(Option 4) This response is based on the idea of client autonomy, but it does not propose a solution to the problem.

Educational objective: A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs, and preferences, and the expertise and evidence-based recommendations of HCPs.

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply.

1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line

2. History of multiple sclerosis with ataxia and diplopia

3. One day postoperative from a hemicolectomy

4. Reporting abdominal pain with coffee ground emesis

5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value

1, 2, 5

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need surgery?" What is the most appropriate action?

1. Call the nursing supervisor

2. Call the operating room scheduler and cancel the surgery

3. Page the health care provider and request clarification on behalf of the client

4. Report the incident to hospital administration

3

Informed consent requires that the health care provider performing the procedure explain everything to the client's satisfaction (within reason). Signed consent may be witnessed by the nurse. If the client does not fully understand informed consent, the nurse must notify the health care provider or refer up the chain of nursing command. The nurse is not responsible for verifying that the client understands the procedure and its respective risks.

(Option 1) This would be appropriate if the health care provider refuses to talk to the client.

(Option 2) This is not the nurse's responsibility; this request would have to be relayed up the chain of nursing command.

(Option 4) This is premature; the incident is isolated and not all facts are known.

Educational objective: Clients may not consent to an invasive procedure without being informed of the clinical reasoning, consequences, and possible complications.

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?

1. Ask a client if the UAP has performed the test

2. Discuss the importance of task completion and accurate documentation in a staff meeting

3. Give the UAP a verbal warning not to falsify data

4. Take a client's capillary glucose personally and compare it to the recorded result

4

The best initial result is to assess and validate the charge nurse's perception. Doing the test and comparing results randomly/intermittently will give data to prove/disprove this concern.

(Option 1) It could cause concern to involve a client when there may be an issue about inadequate provider care. The nurse should handle it independently.

(Option 2) It is good to reinforce policies in general announcements to the entire staff, especially if wide-spread compliance is a concern. However, there is only one person that is suspected of not adhering in this case. Speaking out is often a general step taken, but the intended individuals usually don't hear the information. In addition, this is information that the staff has known/heard before.

(Option 3) The normal discipline process is a verbal warning, a written warning, suspension, and termination. To initiate the process, there has to be evidence of wrong doing. However, it is only a suspicion at this point.

Educational objective: When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?

1. UAP applies the anti-embolism stockings while maintaining the client in supine position

2. UAP carefully smoothes out any wrinkles over the length of the stockings

3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot

4. UAP rolls down and folds over the excess material at the top of the stockings

4

Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn consistently, the stockings decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.

(Option 1) Anti-embolism stockings should be applied before ambulating while the client is in bed; this maximizes the compression effects of the stockings and promotes venous return. The UAP has performed this correctly.

(Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has performed this correctly.

(Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The UAP has performed this correctly.

Educational objective: Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the nurse verifies the stockings are correctly fitted and worn appropriately. Incorrect size and fit or alterations to the stockings can impede venous return.