Podcast
Questions and Answers
What should the nurse do after providing educational materials to the client about the procedure?
What should the nurse do after providing educational materials to the client about the procedure?
Answer the client's question and have the client sign the consent form.
Which statement indicates understanding of the use of mechanical restraints by a newly licensed nurse?
Which statement indicates understanding of the use of mechanical restraints by a newly licensed nurse?
Which client should a medical nurse, without orthopedic experience, be assigned to care for?
Which client should a medical nurse, without orthopedic experience, be assigned to care for?
What should the nurse do when a client with renal failure decides to stop hemodialysis treatment?
What should the nurse do when a client with renal failure decides to stop hemodialysis treatment?
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What action should a charge nurse on the PACU take when an external disaster plan is activated?
What action should a charge nurse on the PACU take when an external disaster plan is activated?
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Which statement by a newly licensed nurse about incident reports indicates understanding?
Which statement by a newly licensed nurse about incident reports indicates understanding?
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What should the ethics committee do when confronted with a dilemma regarding continuing nutritional support for a terminally ill client?
What should the ethics committee do when confronted with a dilemma regarding continuing nutritional support for a terminally ill client?
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Which action requires intervention by the charge nurse?
Which action requires intervention by the charge nurse?
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Which assessment finding should be reported as the priority?
Which assessment finding should be reported as the priority?
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Which action should the nurse manager take during a meeting to achieve a win-win resolution?
Which action should the nurse manager take during a meeting to achieve a win-win resolution?
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Which findings require notification of the provider when planning client care? (Select all that apply)
Which findings require notification of the provider when planning client care? (Select all that apply)
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Which findings indicate the client's condition is worsening and the care plan should be updated? (Select all that apply)
Which findings indicate the client's condition is worsening and the care plan should be updated? (Select all that apply)
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Which findings should the nurse identify as requiring immediate follow-up? (Select 4)
Which findings should the nurse identify as requiring immediate follow-up? (Select 4)
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What should the nurse do first using the nursing process?
What should the nurse do first using the nursing process?
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After developing the initial plan for client discharge, what is the next action the nurse should take?
After developing the initial plan for client discharge, what is the next action the nurse should take?
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What position should the client be in for a routine abdominal assessment?
What position should the client be in for a routine abdominal assessment?
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Which finding is a potential environmental hazard for a family with a toddler?
Which finding is a potential environmental hazard for a family with a toddler?
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What task can be delegated to an assistive personnel (AP) in a maternal newborn unit?
What task can be delegated to an assistive personnel (AP) in a maternal newborn unit?
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Which task should not be assigned to a licensed practical nurse (LPN)?
Which task should not be assigned to a licensed practical nurse (LPN)?
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What indicates understanding of 'do-not-resuscitate' (DNR) orders by an AP?
What indicates understanding of 'do-not-resuscitate' (DNR) orders by an AP?
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What action should the nurse take to validate the client's understanding of a procedure before it is performed?
What action should the nurse take to validate the client's understanding of a procedure before it is performed?
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What is the nurse's first action upon notification of a fire on the unit?
What is the nurse's first action upon notification of a fire on the unit?
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What should the nurse do if a client refuses a recommended surgical procedure?
What should the nurse do if a client refuses a recommended surgical procedure?
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Which behavior could indicate that a staff nurse might be working while impaired?
Which behavior could indicate that a staff nurse might be working while impaired?
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What should a nurse do after being reprimanded by a provider in front of a client?
What should a nurse do after being reprimanded by a provider in front of a client?
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Which client should the nurse assess first in triage following a motor vehicle crash?
Which client should the nurse assess first in triage following a motor vehicle crash?
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What should the nurse verify regarding a transfer client's informed consent?
What should the nurse verify regarding a transfer client's informed consent?
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What information should the nurse report in a verbal report for a client post-surgery?
What information should the nurse report in a verbal report for a client post-surgery?
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What should a nurse manager include in an annual performance review?
What should a nurse manager include in an annual performance review?
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How should a charge nurse respond to an AP's complaint about unfair workload?
How should a charge nurse respond to an AP's complaint about unfair workload?
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Which client should the nurse assess first during shift report?
Which client should the nurse assess first during shift report?
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What demonstrates the nurse's advocacy regarding a client with a mutation of the BRCA2 gene?
What demonstrates the nurse's advocacy regarding a client with a mutation of the BRCA2 gene?
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What should a nurse do if they observe non-compliance with pain assessment protocols?
What should a nurse do if they observe non-compliance with pain assessment protocols?
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What is the first action when developing a plan to improve hand hygiene adherence?
What is the first action when developing a plan to improve hand hygiene adherence?
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What action should a nurse take regarding a client with a living will that denies artificial nutrition?
What action should a nurse take regarding a client with a living will that denies artificial nutrition?
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How should a charge nurse approach a conflict between two nurses over workload sharing?
How should a charge nurse approach a conflict between two nurses over workload sharing?
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What action should the nurse take if a client has questions about surgical alternatives?
What action should the nurse take if a client has questions about surgical alternatives?
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Which of the following findings should the nurse identify require follow-up by the provider? (Select the 6 findings that require immediate follow-up)
Which of the following findings should the nurse identify require follow-up by the provider? (Select the 6 findings that require immediate follow-up)
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Which of the following interventions is appropriate for the plan of care for a client who has active herpes simplex lesions?
Which of the following interventions is appropriate for the plan of care for a client who has active herpes simplex lesions?
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Which action should the nurse take to maintain client confidentiality?
Which action should the nurse take to maintain client confidentiality?
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Which statement is an example of using the conflict resolution strategy known as smoothing?
Which statement is an example of using the conflict resolution strategy known as smoothing?
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What is the priority action for a nurse manager planning daily work and activities for the unit?
What is the priority action for a nurse manager planning daily work and activities for the unit?
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Informed consent should be given by which of the following people for a school-age client with a laceration?
Informed consent should be given by which of the following people for a school-age client with a laceration?
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What should the nurse do for a client uncertain about undergoing a tubal ligation?
What should the nurse do for a client uncertain about undergoing a tubal ligation?
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Which of the following tasks is appropriate to delegate to a licensed practical nurse (LPN)?
Which of the following tasks is appropriate to delegate to a licensed practical nurse (LPN)?
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What should the nurse do first upon seeing staff members looking at the electronic medical record for a celebrity client?
What should the nurse do first upon seeing staff members looking at the electronic medical record for a celebrity client?
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Which instruction reflects effective communication regarding delegation to an assistive personnel (AP)?
Which instruction reflects effective communication regarding delegation to an assistive personnel (AP)?
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Which response should the nurse make to a client who does not want to continue chemotherapy?
Which response should the nurse make to a client who does not want to continue chemotherapy?
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Which resources should the nurse consult when planning for a policy creation allowing nurses to insert PICC lines?
Which resources should the nurse consult when planning for a policy creation allowing nurses to insert PICC lines?
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What is the first step in addressing an increase in health care-associated UTIs on a medical-surgical unit?
What is the first step in addressing an increase in health care-associated UTIs on a medical-surgical unit?
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Which client's finding should receive a class III, or green tag, in a triage situation?
Which client's finding should receive a class III, or green tag, in a triage situation?
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What was the first action a nurse should take when observing smoke from a wastebasket?
What was the first action a nurse should take when observing smoke from a wastebasket?
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What response should the charge nurse make to a staff nurse's concern that a client is seeking drugs?
What response should the charge nurse make to a staff nurse's concern that a client is seeking drugs?
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Which statement reflects an intrapersonal conflict?
Which statement reflects an intrapersonal conflict?
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What action should the case manager perform prior to discharging a client requiring IV antibiotics at home?
What action should the case manager perform prior to discharging a client requiring IV antibiotics at home?
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For a client with dementia being admitted for surgery, which action promotes safety?
For a client with dementia being admitted for surgery, which action promotes safety?
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Which statement from an assistive personnel (AP) indicates the nurse should assess the client first?
Which statement from an assistive personnel (AP) indicates the nurse should assess the client first?
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What response should the nurse make when a client claims informed consent was not obtained for an indwelling urinary catheter?
What response should the nurse make when a client claims informed consent was not obtained for an indwelling urinary catheter?
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What action should the nurse take after receiving a change-of-shift report?
What action should the nurse take after receiving a change-of-shift report?
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Which action should the nurse take to ensure the competency of the AP regarding removal of a client's urinary catheter?
Which action should the nurse take to ensure the competency of the AP regarding removal of a client's urinary catheter?
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After a client reports staff members are not answering the call light promptly, what should the nurse do first?
After a client reports staff members are not answering the call light promptly, what should the nurse do first?
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Study Notes
Postoperative Care Observations
- Immediate follow-up required for increased heart rate, respiratory rate, and pain level of 8 post-abdominal surgery.
- Large amounts of bright red blood at the incision site indicate possible hemorrhage.
- Decreased blood pressure and oxygen saturation are critical signs for intervention.
Herpes Simplex Infection Care
- Use contact precautions when caring for clients with herpes simplex lesions.
- Barriers such as gowns and gloves are essential for prevention of infection spread.
Maintaining Client Confidentiality
- Inform partners that laboratory test results cannot be disclosed without client permission.
- Verbal permission is necessary for discussing client names in academic settings.
Conflict Resolution Strategy
- "You always complete your work on time..." is an example of smoothing, where a compliment is used to minimize conflict emotions.
Nurse Manager's Priorities
- Assigning client care to staff is the highest priority for ensuring timely treatments and continuity of care.
Informed Consent for Minors
- The client’s guardian must give informed consent for medical procedures involving minors.
Supporting Client Decision Making
- Discussing feelings about a tubal ligation procedure is key to supporting the client's autonomy in decision-making.
Delegation in Nursing
- Suctioning a client with a chronic tracheostomy can be appropriately delegated to a licensed practical nurse (LPN).
Breach of Confidentiality
- Immediate intervention is required if staff members access confidential records without authorization.
Effective Delegation Communication
- Clear instructions should include specific tasks, client information, a timeline, and expectations for reporting back.
Palliative Care Options
- Acknowledge the client's right to refuse treatment while offering information about palliative care options as support.
Policy Development in Nursing
- Consult the State Nurse Practice Act for regulatory guidelines regarding expanded nursing functions.
Quality Improvement in Healthcare
- Establish best practice guidelines as the first step in addressing health care-associated urinary tract infections.
Triage in Emergencies
- Class Ill (green tag) should be assigned to clients with less severe injuries, such as facial contusions.
Fire Safety Protocol
- According to RACE, transporting the client to safety is the first priority when fire is detected.
Pain Management Acknowledgment
- Nurses should affirm that clients are the best indicators of their pain experiences.
Intrapersonal Conflict Examples
- Uncertainty about applying for a promotion or starting a family reflects intrapersonal conflict stemming from competing desires.
Case Management Responsibilities
- Ensuring home infusion therapy is arranged is crucial for a client transitioning home post-IV antibiotic treatment.
Client Safety for Dementia Patients
- Placing clients with dementia near the nurses' station promotes safety and frequent monitoring.
Client Assessment Prioritization
- Assess clients who report inability to void post-indwelling urinary catheter removal as this indicates potential urinary retention risks.
Informed Consent Misunderstandings
- Insertion of an indwelling urinary catheter does not require written informed consent; compliance implies consent.
Nursing Shift Responsibilities
- Obtaining a capillary blood glucose reading is essential before administering scheduled insulin.
Competency Assurance
- Reviewing an assistive personnel's skill competency checklist ensures they are qualified for tasks like catheter removal.
Addressing Client Concerns
- Asking the client to express their expectations regarding staff response times is the first step in addressing their concerns.
Policy Revision Processes
- Determining goals and objectives is a crucial next step after developing an initial policy revision plan.
Abdominal Assessment Protocol
- Place the client in a dorsal recumbent position to facilitate accurate abdominal assessments.
Home Safety Assessments for Toddlers
- Conduct comprehensive evaluations of potential safety hazards in homes with toddlers during home health assessments.### Environmental Hazards for Toddlers
- Raised toilet seat lid presents a risk of accidental drowning for toddlers.
Delegating Tasks
- Assistive personnel (AP) can measure urine output of the client's first voiding.
- Licensed practical nurses (LPNs) can provide enteral feeding to clients like those with Crohn's disease.
Understanding DNR Orders
- APs should contact the nurse if unable to detect a client's pulse, rather than perform resuscitation.
Validating Informed Consent
- A client’s understanding of a procedure is confirmed by asking them to verbalize its purpose, risks, and benefits.
Fire Emergency Response
- Prioritize assisting clients in immediate danger during a fire incident.
Client Autonomy and Surgery
- Discuss a client's concerns about surgery, emphasizing open communication to understand their perspective.
Identifying Impairment in Nurses
- Frequent restroom use by a nurse may indicate impairment, alongside errors and mood swings.
Conflict Resolution
- Address conflicts between nurses by discussing situations privately to promote understanding and resolve issues.
Triage in Emergency Situations
- A client with asymmetrical thoracic movement after a crash may have a tension pneumothorax and must be prioritized for assessment.
Informed Consent in Medical Procedures
- Ensure consent is documented prior to procedures involving moderate sedation.
Postoperative Care Reporting
- Include the client’s level of consciousness in verbal reports to maintain effective communication.
Annual Performance Evaluations
- Include peer evaluations and self-appraisals in performance reviews to reflect a nurse's performance comprehensively.
Delegation and Fair Work Distribution
- Charges nurses should be transparent about task delegation based on job responsibilities to address AP concerns.
Client Priority During Shift Changes
- Assess clients who show signs of instability, such as elevated heart rate post-surgery, first during shift changes.
Client Advocacy for Genetic Testing Results
- Encourage clients to discuss their understanding of test results, respecting their decisions while advocating for their health.
Adherence to Pain Assessment Policies
- Report issues of non-compliance with pain assessment policies to management for resolution.
Hand Hygiene Improvement Plans
- Establish goals for improving hand hygiene adherence as the first step in addressing adherence rates.
Ethical Considerations and Living Wills
- Review client wishes as stated in their living wills with family, especially regarding life-sustaining treatments like tube feeding.
Conflict Management in Nursing Units
- Encourage collaboration between conflicting nurses to evaluate workflow and foster resolution.
Consent for Surgical Procedures
- Direct clients’ questions about alternative treatments to the provider for clarification and transparency.
Regulations on Mechanical Restraints
- A provider must evaluate a client within 1 hour of applying mechanical restraints to ensure proper oversight.
Assignment of Nursing Tasks
- A medical nurse can care for clients with non-specialized needs, such as recent amputations, due to a lack of immediate specialized care needed.
Supporting Client Decisions
- Nurses should support clients' decisions regarding the discontinuation of treatments like hemodialysis, reinforcing their autonomy.
Emergency Preparedness in Disasters
- In disasters, charge nurses should assess stable clients for transfer to ensure efficient care delivery during crises.
Understanding Incident Reports
- Complete incident reports for unexpected occurrences, but do not place copies in clients' medical records to maintain confidentiality.### Incident Reporting
- Completion of incident reports is essential for analyzing unexpected occurrences and deviations from care standards.
Ethics Committee Involvement
- Ethics committees aid in resolving dilemmas, such as disagreements over continuing nutritional support for terminally ill clients.
- The committee's role includes assisting in weighing options and examining all relevant facts; however, they do not make final decisions or provide legal representation.
Charge Nurse Responsibilities
- A charge nurse must intervene if a nurse photocopies a client’s diagnostic test results due to confidentiality and privacy breaches.
- Documentation and sharing of client information must adhere strictly to privacy regulations.
Priority Assessment in Nursing
- Postoperative clients with urine output below the expected range (e.g., 20 mL/hr) must be reported as they may indicate critical issues like hypovolemia or renal failure.
- Other findings, such as mild edema, heart rate changes, or nausea, may warrant monitoring but are less urgent.
Conflict Resolution in Nursing Management
- Effective conflict resolution involves collaboration among staff to achieve mutual goals and minimize workplace tension.
- Encouraging competitors or avoidance strategies typically do not lead to sustainable solutions.
Monitoring Client Health Indicators
- Critical findings warranting notification to healthcare providers include increased heart rate, temperature, WBC count, decreased blood pressure, and lower prealbumin levels indicating possible wound infection and risk for sepsis.
Recognizing Substance Use Disorder in Employees
- Warning signs of substance use disorder in nurses may include attendance issues, mood swings, hygiene decline, changes in social habits, and client complaints about pain management.
- Immediate action involves removing the nurse from the unit if substance abuse is suspected.
Evaluating Client Care Plans
- Indicators that suggest a worsening condition in clients include blood-tinged sputum, elevated temperature, increased heart and respiratory rates, and decreased oxygen saturation levels, particularly in patients with pneumonia.
Follow-Up Requirements for Critical Findings
- Immediate follow-up is necessary for clients showing weakness, nausea, diaphoresis, abnormal ECG results, low oxygen saturation, and significant changes in blood pressure and respiratory rate, suggesting potential angina or urgent health issues.
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Test your knowledge with the RN Leadership Online Practice flashcards for 2023B. This quiz focuses on identifying critical findings that require immediate follow-up by the provider in a postoperative patient scenario. Perfect for nursing students and professionals preparing for their evaluations.
