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EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A nurse is caring for a group of clients on a medical unit. Which of the following is the priority finding the nurse should report to the provider?
A. A client receiving metoclopramide (Reglan) reports diarrhea
B. A client receiving tamsulosin (Flomax) reports feeling dizzy
C. A client receiving cephalexin (Keflex) reports dyspnea
D. A client receiving erythromycin (E-Mycin) reports epigastric pain - ansC
A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client's son asks the nurse what med is being given to the client. Which of the following is an appropriate response by the nurse?
A. "I am sorry, but that is information you will need to ask your mother or her doctor."
B. "Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan) for anxiety."
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
C. "You will need to ask the charge nurse for that info."
D. "Don't worry. We will give your mother all pertinent info before discharge." - ansA.
A nurse is observing a newly licensed nurse & an AP pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates a need for further education?
A. The nurse spreads his legs apart
B. The nurse uses his body weight to counter the client's weight
C. The nurse's feet are facing inward, toward the center of the bed
D. The nurse uses the muscles in his arms to lift the client off the bed using the drawsheet -
ansC A nurse is overheard telling other nurses that the unit manager gives preferential treatment to nurses on the night shift. Which of the following approaches by the unit manager reflects an assertive response to resolution of this conflict?
A. Understand that the vocal nurse is misinformed & take no action.
B. Assign the vocal staff nurse to work the night shift to allow direct experience w/the night shift.
C. Meet one-on-one w/the vocal staff nurse to discuss the concerns raised
D. Confront the staff nurse during the next unit meeting regarding her statement - ansC
A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following will provide the most relevant info regarding the efficacy of the procedure?
A. Frequency w/which the procedure is performed
B. Client satisfaction w/performance of procedure
C. Incidence of complications r/t procedure
D. Accurate documentation of how the procedure was performed - ansC
A nurse is participating in an interprofessional conference for a client who has a recent C6 spinal cord injury. The client worked as a construction worker prior to his injury. Which of the following members of the interprofessional team should also participate in planning care for this client? Select all that apply.
A. Physical therapist
B. Speech therapist
C. Occupational therapist
D. Psychologist
E. Vocational counselor - ansA, C, D, E
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
The actual writing of an expected outcome is done in the planning phase of the nursing care plan. A nurse manager finds an increased incidence of health-care associated infections (HAIs) on a long term care unit. Which of the following is the priority action the nurse manager should take to address the problem?
A. Monitor the staff's hand hygiene techniques
B. Hold a mandatory in-service about hand hygiene & infection rates
C. Require nurses to take an online course on HAIs
D. Conduct a chart review to gather data about clients who developed HAIs - ansD
A nurse manager has received a performance appraisal from the unit manager. Which of the following actions by the unit manager requires intervention?
A. The evaluation was conducted in the unit manager's office
B. Data that was collected for the previous 12 months was presented
C. Verbal concerns provided by a staff member were incorporated into the data
D. The nurse was asked to review the performance appraisal & complete a self- evaluation -
ansC A nurse manager is about to write a 2 month performance appraisal for a newly graduated nurse. Which of the following factors should the nurse manager take into consideration when planning a performance appraisal interview for this nurse?
A. The written appraisal & interview should sound friendly & be informal
B. No one except the nurse manager should have input regarding the nurses's appraisal
C. A nursing administrator who does not know the nurse should conduct the interview to promote
fairness
D. The nurse should have a copy of performance standards before the appraisal interview - ansD
A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? Select all that apply.
A. A description of the incident should be documented in the client's health care record
B. Incident reports should not be shared w/the client
C. Incident reports include a description of the incident & actions taken
D. A copy of the incident report should be placed in the client's health care record
E. The risk management dept. investigates the incident - ansA, B, C, E
A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select all that apply.
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A. Discussing treatment options w/a client who was pancreatic cancer
B. Notifying the surgeon when a client signing a surgical consent form has questions about the
procedure
C. Helping a client make a list of questions she would like to ask the provider
D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function
E. Carrying out end-of-life wishes outlined in the living will of an older adult - ansB, C, D, E
A nurse manager is providing info about the audit process to members of the nursing team. Which of the following statements should the nurse manager include? Select all that apply.
A. A structure audit evaluates the setting & resources available to provide care
B. An outcome audit evaluates the results of the nursing care provided
C. A root cause analysis is indicated when a sentinel event occurs
D. Retrospective audits are conducted while the client is receiving care
E. After data collection is completed, it is compared to a benchmark - ansA, B, C, E
A nurse manager is providing info to the nurses on the unit about ensuring client rights. Which of the following outlines the rights of individuals in health care settings?
A. American Nurses Association Code of Ethics
B. HIPAA
C. Patient Self-Determination Act
D. Patient Care Partnership - ansD
A nurse manager is reviewing the function of "Code of Ethics for Nurses with Interpretive Statements" during a staff meeting. The nurse manager recognizes that this document is:
A. legally binding
B. mandatory for the practice of nursing
C. a description of requirements for licensure
D. a guide for professional actions - ansD.
A nurse manager is working with a committee of nurses whose task is to update the policies for new employee orientation. The nurse manager directs the team to collect as much data as possible & recommend several options. Which of the following decision- making styles is being demonstrated by the nurse manager?
A. Decisive
B. Flexible
C. Hierarchical
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
E. Support team member requests for referral - ansB, D, E
A nurse working at a rehab facility attends an interdisciplinary team meeting for a client who has had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse expect to contribute to the plan of care? Select all that apply.
A. Nurse
B. Occupational therapist
C. Speech therapist
D. Physical therapist
E. Respiratory therapist - ansA, B, C, D
A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the following describes a case management approach to care?
A. A nurse provides total care for several clients
B. Collaboration between disciplines creates a multidisciplinary care plan for each client.
C. The focus of care is on detecting disorders at an early stage.
D. The team leader assigns care for a group of clients - ansB
Airway Management: Discharge planning for a Client Who Has a Tracheostomy - ansAlways have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times. Airway Management: Discharge planning for a Client Who Has a Tracheostomy - ansAlways have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times. An AP reports that a client's finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client's morning finger-stick blood glucose was 285 mg/dL. The client is asymptomatic for hypoglycemia, & his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?
A. Recalibrate the glucometer, & recheck the client's blood glucose
B. Have the lab draw a stat serum glucose
C. Inform the AP to give the client 120 mL of orange juice
D. Administer insulin as prescribed - ansA
An LPN can perform care. - anstracheostomy care
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
An older adult client who has early Alzheimer's disease is living w/an adult child who is employed part- time but is committed to keeping her parent at home. Which of the following options is appropriate for the nurse to discuss w/the client & family at this time?
A. Hospice care
B. Adult day care
C. An assisted-living facility
D. Long-term care facility - ansB
An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first?
A. Call the client's provider
B. Ask a staff member for assistance getting the client back in bed
C. Inspect the client for injuries
D. Ask the client why he got out of bed w/out assistance - ansC. Inspect the client for injuries
An RN has to teach the client initially but can delegate to an LPN. - ansreinforcing the teaching An RN on a med-surg unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN?
A. Obtain vitals for a client who is 2 hr postop following a cardiac cath
B. Administering a unit of PRBCs
C. Instructing a client in the performance of wound care
D. Developing a plan of care for a newly admitted client - ansA
An RN working w/an LPN is planning client care assignments. Which of the following tasks should the nurse delegate to the LPN?
A. Performing tracheostomy suctioning for a stable client
B. Performing an admission assessment of a client who is preop
C. Initiating the referral of a client to hospice
D. Interpreting a client's digoxin level - ansA
Can an RN delegate to an AP to feed a client not on swallow precautions? - ansyes Can an RN delegate to an LPN to perform suctioning? - ansyes Can an RN delegate to an LPN to put in a urinary catheter? - ansyes
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined. Managing Client Care: Performance Improvement Process - ansStandards are made available to employees by way of polices and procedures. Quality issues are identified by staff, management, or risk management department. an inter professional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data is collected. If benchmark is not met, possible influencing factors are determined. Managing Client Care: Prioritizing Client Care - ansSystemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don't assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action. Managing Client Care: Prioritizing Client Care - ansSystemic before local. Acute before chronic. Actual problems before potential problems. Listen carefully to clients and don't assume. Recognize and response to trends vs. transit findings. Recognize indications of medical emergencies & complications vs expected findings. Apply clinical knowledge to procedural standards to determine the priority action. Preoperative Nursing Care: Securing Client Belongings - ansGive all pt belongings to family member to safely stored. Preoperative Nursing Care: Securing Client Belongings - ansGive all pt belongings to family member to safely stored. Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
- ansInflammation means that the body's immune system is working to heal the wound.
Pressure Ulcers, Wounds, and Wound Management: Assessing for Evidence of Healing
- ansInflammation means that the body's immune system is working to heal the wound.
Professional Responsibilities: Adhering to Ethical Principles - ansJustice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness). Professional Responsibilities: Adhering to Ethical Principles - ansJustice (fair treatment), beneficence (doing good), nonmaleficence (doing no harm), fidelity (faithfulness), autonomy (independence), veracity (truthfulness). Professional Responsibilities: Identifying a Tort - ansA wrongful act or an infringement of a right
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
Professional Responsibilities: Identifying a Tort - ansA wrongful act or an infringement of a right Professional Responsibilities: Obtaining Informed Consent in an Emergency - ansInformed consent is not needed if the pt is unconscious and surgery is immediately required to save their life. Professional Responsibilities: Obtaining Informed Consent in an Emergency - ansInformed consent is not needed if the pt is unconscious and surgery is immediately required to save their life. Professional Responsibilities: Responding to a Visitor's Question About Status of a Client - ansInformation cannot be shared with unauthorized individuals, including family members, unless they provide the code. Professional Responsibilities: Responding to a Visitor's Question About Status of a Client - ansInformation cannot be shared with unauthorized individuals, including family members, unless they provide the code. Professional Responsibilities: Teaching About Confidentiality - ansClient medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions. Professional Responsibilities: Teaching About Confidentiality - ansClient medical records must be kept in secure area. No information can be written on public display boards. EMR should be password protected, and nurses must only use their own log-in information. No part of the medical record can be copied, except for authorized exchange of documents between health care institutions. A charge nurse on a med surg unit is assigning client care to an RN and an LPN. Which of the following tasks should the nurse assign to the RN? Select all that apply.
A. Performing colostomy care
B. Administering blood to a client
C. Developing a plan of care for a client
D. Calculating a TPN flow rate
E. Checking nasogastric tube patency - ansB, C, D
A client is brought back to the unit after a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocate the new hip joint, & repeatedly
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A. Call the client's provider B. Monitor the client's vitals C. Notify the risk manager D. Complete an incident report E. Instruct the client to remain in bed until further notice - ans1. B
- E
- A
- D
- C A nurse has prepared an IM injection for a client who is preoperative, when another client suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is waiting to take the client to surgery. Which of the following is an appropriate action by the LPN?
A. Prepare a new syringe for the client who is preop
B. Give the prepared med to the client who is preop
C. Help the client requesting assistance so the nurse can give the prepared injection
D. Report this request to the charge nurse - ansC
A nurse is assessing a client's negligible progress in following a weight loss program. Which of the following is a likely reason the client was unable to achieve a short-term goal established during the planning phase of the nursing process?
A. The goals were realistic & formulated w/client input.
B. The underlying problem behind past weight gain was misidentified.
C. The implementation of the plan used flexibility in following the nursing actions
D. The nurse obtained objective & subjective data during the assessment. - ansB
A nurse is caring for a client who has recently been prescribed lithium carbonate (Eskalith). Which of the following is the priority assessment finding for this client?
A. Fine hand tremors
B. Weight gain of 2.7 kg (6 lb)
C. Report of nausea
D. Poor motor coordination - ansD
A nurse is caring for a client who is being prepared for surgery. The client hands the nurse info about advance directives & states, "Here, I don't need this. I am too young to worry about life-sustaining measures & what I want done for me." Which of the following actions should the nurse take?
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A. Return the papers to the admitting dept w/a note stating that the client doesn't wish to address the
issue at this time.
B. Explain to the client that you never know what can happen during surgery & that he should fill the
paper's out "just in case."
C. Contact a client representative to talk w/the client & offer additional info about the purpose of
advance directives
D. Inform the client that the surgery cannot be conducted unless he completes his advance
directives forms - ansC A nurse is caring for a group of clients on a med surg unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? Select all that apply.
A. Collecting a stool specimen
B. Providing instructions about using a spirometer
C. Measuring oral intake
D. Providing postmortem care
E. Changing a dressing - ansA, C, D
A nurse is caring for a group of clients on a medical unit. Which of the following is the priority finding the nurse should report to the provider?
A. A client receiving metoclopramide (Reglan) reports diarrhea
B. A client receiving tamsulosin (Flomax) reports feeling dizzy
C. A client receiving cephalexin (Keflex) reports dyspnea
D. A client receiving erythromycin (E-Mycin) reports epigastric pain - ansC
A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client's son asks the nurse what med is being given to the client. Which of the following is an appropriate response by the nurse?
A. "I am sorry, but that is information you will need to ask your mother or her doctor."
B. "Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan) for anxiety."
C. "You will need to ask the charge nurse for that info."
D. "Don't worry. We will give your mother all pertinent info before discharge." - ansA.
A nurse is observing a newly licensed nurse & an AP pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates a need for further education?
A. The nurse spreads his legs apart
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A nurse is reviewing a client's health care record & discovers that the client's DNR order has expired. The client's condition is not stable. Which of the following actions should the nurse take?
A. Assume that the client does not want be resuscitated, & take no action if she experiences
cardiac arrest
B. Write a note on the front of the provider order sheet asking that the DNR order be reordered
C. Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest
D. Call the provider to determine whether the order should be immediately reinstated - ansD
A nurse is serving as a preceptor to a newly licensed nurse & is explaining the role of the nurse as advocate. Which of the following situations illustrates the advocacy role? Select all that apply.
A. Verifying that a client understands what is done during a cardiac catheterization
B. Discussing treatment options for a terminal diagnosis
C. Informing members of the health care team that a client has DNR status
D. Reporting that a health team member on the previous shift did not provide care as prescribed
E. Assisting a client to make a decision about his care based on the nurse's
recommendations - ansA, C, D A nurse is writing a goal for a client's reaction following the admin of a med. Which of the following phases of the nursing process should the nurse modify?
A. Planning
B. Evaluation
C. Analyzing
D. Assessment - ansA
The actual writing of an expected outcome is done in the planning phase of the nursing care plan. A nurse manager finds an increased incidence of health-care associated infections (HAIs) on a long term care unit. Which of the following is the priority action the nurse manager should take to address the problem?
A. Monitor the staff's hand hygiene techniques
B. Hold a mandatory in-service about hand hygiene & infection rates
C. Require nurses to take an online course on HAIs
D. Conduct a chart review to gather data about clients who developed HAIs - ansD
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
A nurse manager has received a performance appraisal from the unit manager. Which of the following actions by the unit manager requires intervention?
A. The evaluation was conducted in the unit manager's office
B. Data that was collected for the previous 12 months was presented
C. Verbal concerns provided by a staff member were incorporated into the data
D. The nurse was asked to review the performance appraisal & complete a self- evaluation -
ansC A nurse manager is about to write a 2 month performance appraisal for a newly graduated nurse. Which of the following factors should the nurse manager take into consideration when planning a performance appraisal interview for this nurse?
A. The written appraisal & interview should sound friendly & be informal
B. No one except the nurse manager should have input regarding the nurses's appraisal
C. A nursing administrator who does not know the nurse should conduct the interview to promote
fairness
D. The nurse should have a copy of performance standards before the appraisal interview - ansD
A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following statements should the nurse manager include? Select all that apply.
A. A description of the incident should be documented in the client's health care record
B. Incident reports should not be shared w/the client
C. Incident reports include a description of the incident & actions taken
D. A copy of the incident report should be placed in the client's health care record
E. The risk management dept. investigates the incident - ansA, B, C, E
A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select all that apply.
A. Discussing treatment options w/a client who was pancreatic cancer
B. Notifying the surgeon when a client signing a surgical consent form has questions about the
procedure
C. Helping a client make a list of questions she would like to ask the provider
D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function
E. Carrying out end-of-life wishes outlined in the living will of an older adult - ansB, C, D, E
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
Notify the provider - ans1. Measure the client's vitals
2. Instruct the client to call for assistance when getting out of bed
3. Notify provider
4. Complete an incident report
5. Contact the risk manager
A nurse on a med surg unit is planning care of assigned clients. Which of the following clients should the nurse assess first?
A. A client who is newly admitted & is to have an indwelling urinary catheter inserted
B. A client who has kidney stones & reports flank pain 6 out of 10
C. A client diagnosed w/early-stage chronic kidney disease w/a serum creatinine level of 2.0 mg/dL
D. A client who has a cast newly applied on his forearm and reports tingling of his fingers - ansD
A nurse overhears a client talking with an attorney, reporting physical abuse, use of restraints & denial of meals. What action should the nurse take?
A. Report the conversation to the nurse manager to allow for follow-up investigation.
B. Question the client about the allegations to identify staff who were allegedly involved.
C. Ignore the conversation unless the client brings it to the attention of the nurse.
D. Recognize this as a privileged communication that cannot be discussed w/anyone. - ansA
A nurse who has just assumed the role of unit manager is examining her skills in interprofressional collaboration. Which of the following actions support interprofessional collaboration? Select all that apply.
A. Use aggressive communication when addressing the team
B. Recognize the knowledge & skills of each member of the team
C. Ensure that a nurse is assigned to serve as the group facilitator for all
interdisciplinary meetings
D. Encourage the client & family to participate in the team meeting
E. Support team member requests for referral - ansB, D, E
A nurse working at a rehab facility attends an interdisciplinary team meeting for a client who has had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse expect to contribute to the plan of care? Select all that apply.
A. Nurse
B. Occupational therapist
C. Speech therapist
EXAM QUESTIONS AND CORRECT ANSWERS(ALL
ANSWERS ARE CORRECT)|AGRADE
D. Physical therapist
E. Respiratory therapist - ansA, B, C, D
A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the following describes a case management approach to care?
A. A nurse provides total care for several clients
B. Collaboration between disciplines creates a multidisciplinary care plan for each client.
C. The focus of care is on detecting disorders at an early stage.
D. The team leader assigns care for a group of clients - ansB
Airway Management: Discharge planning for a Client Who Has a Tracheostomy - ansAlways have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times. Airway Management: Discharge planning for a Client Who Has a Tracheostomy - ansAlways have two extra trach tubes (one your size and one size smaller). Keep an obturator for each trach tube and trach ties. Keep sterile saline and lubricant with you at all times. An AP reports that a client's finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client's morning finger-stick blood glucose was 285 mg/dL. The client is asymptomatic for hypoglycemia, & his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first?
A. Recalibrate the glucometer, & recheck the client's blood glucose
B. Have the lab draw a stat serum glucose
C. Inform the AP to give the client 120 mL of orange juice
D. Administer insulin as prescribed - ansA
An LPN can perform care. - anstracheostomy care An older adult client who has early Alzheimer's disease is living w/an adult child who is employed part- time but is committed to keeping her parent at home. Which of the following options is appropriate for the nurse to discuss w/the client & family at this time?
A. Hospice care
B. Adult day care
C. An assisted-living facility
D. Long-term care facility - ansB
