ATI Leadership Study Guide

ATI Leadership Study Guide A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team? Occupational therapist. Which of the following inst...

ATI Leadership Study Guide A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team? Occupational therapist. Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)? Check the urinary output at 11:00 for John Doe and report it to me immediately.” A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion? Interpreter A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values? Platelets 100,000/mm³ A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy? State Nurse Practice Act A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take? Inform the assistive personnel of the client's weight-bearing status. A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task? Review the AP's skill competency checklist. A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take? Discuss the client's concerns about having the surgery. A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first? Remind the staff members that this is a breach of confidentiality. A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take? Notify the quality improvement team A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)? Determine a client's intake and output A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care? Provide the client with information about advance directives. A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take? Role model a positive approach to the changes, Redirect the conversation when staff members make negative comments about the changes. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A client who has peripheral vascular disease and has an absent pulse in the right foot. A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take? Inform the client of the consequences of refusing the medication. A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions? Wear an N95 respirator mask when in the client's room. A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "Clients on a mental health unit can refuse their medication. A facility has been notified of a train derailment resulting in multiple clients experiencing life- threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take? Identify stable clients for transfer to a surgical unit. A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)? Provide an enteral feeding to a client who has Crohn's disease. A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first? "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.” A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first? "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.” A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures? Receiving moderate sedation. A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first? Perform a chart review to gather data about the clients who developed infections. A charge nurse recognizes a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the charge nurse take first? Explore the reasons that staff are not attending the meetings. A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care? Advise the client to install grab bars in the bathroom at home. A client on a general surgical unit tells a nurse that staff members are not answering the call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first? Ask the client to verbalize their expectations. A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 minutes. The nurse is demonstrating which of the following ethical principles? Fidelity. A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make? "Clients are the experts on their own pain.” A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse? A client who had a right above-the-knee amputation 24 hours ago. A nurse is caring for a 19-year-old client who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make? "I will gather information about palliative care for you.” A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn? Home Health. A charge nurse is observing a newly licensed nurse's use of time-management skills. Which of the following actions by the newly licensed nurse indicates effective use of this skill? Groups tasks that are in the same location. A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique? The nurse places the sterile package with the top flap opening away from the body. A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make? "This is a procedure that does not require written informed consent.” A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make? "Your case manager will coordinate the resources you will need.” A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care? The length of the client's stay. A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A nurse is photocopying their assigned client's diagnostic test results. A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take? Place the client in a dorsal recumbent position for the examination. A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching? Wear an N95 respirator mask while caring for these clients. A nurse is caring for a client who is 3 days postoperative following open-heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report? The client's level of consciousness. A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take? Pick up the first sterile glove by grasping the folded cuff edge. A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching? Access to client information is limited to direct care providers.” A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first? A client who has a sucking chest wound. A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.). A. The right to be treated with respect and dignity. B. The right to full access of the facility. D. The right to leave regardless of provider recommendations. E. The right to be fully informed of their health conditions. A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority? Obtain the client's serum potassium level. A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first? Assist clients who are in immediate danger to a safe location. A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take? Assist in weighing the options involved in the decision. A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next? Determine goals and objectives. A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue? Inform the staff of the penalties that can result from medication errors. A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority? The child has several small bruises on both legs. A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take? Review the client's request with the family. A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference? The client refuses to attend physical therapy sessions. A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need? Social services A nurse is caring for four clients. Which of the following assessment findings is the priority? A client who has a femur fracture and reports feeling short of breath. A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan? Compare data from clients' records regarding skin integrity with established criteria. A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take? Provide information about alternate birth control methods. Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should approach this conflict in which of the following ways? Explore alternative solutions to address unit workflow with the nurses. A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired? Frequent use of restroom. A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent? Ask the client to explain the procedure that is being performed. An assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make? "I delegate tasks to personnel based on their job descriptions.” A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? A nurse can disclose information to a family member with the client’s permission.” A nurse manager observes an assistive personnel incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first? Help the AP assist the client with the transfer A nurse enters a client’s room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take? Inform the provider that the client requires clarification about the procedure A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need? Social services A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to include? Provide an interpreter when obtaining consent from the client A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse? Opens irrigation supplies before removing the soiled dressing A nurse is preparing to discharge a client who has end-stage heart failure. The client’s partner tells the nurse she can no longer handle the client. Which of the following actions should the nurse take? Contact the case manager to discuss discharge options A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority? A client who has soot markings around each naris following a house fire To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using? Competing A nurse in the emergency department is assessing a client who is unconscious following a motor- vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? Transport the client to the operating room without verifying informed consent A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? A client who is at 35 weeks of gestation and has a biophysical profile of 6 A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescription in the client’s medical record? Morphine sulfate 10 mg IV q 4 hr IV prn for pain A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? Decreased level of consciousness A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent? A client who has an asymmetrical thorax A nurse manager is leading a discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma? A parent wants her 14-year-old adolescent to receive radiation treatment against his will A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique? Instructing the client to place her chin toward her chest when swallowing A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? Battery A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? “I should encrypt personal health information when sending emails.” A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first? Inadequate food supply or Low pain tolerance A charge nurse making rounds observes that an assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? Remove the restraints from the client’s wrists A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse? A client who is scheduled for an endoscopy later today and requires an enema A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? Recommend that he take time to plan at the beginning of his shift A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following action should the nurse take? Contact a family member to come and sit with the client A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? A health care proxy can make decisions for you when you are unable to do so A nurse on a medical-surgical unit is evaluating an assistive personnel’s use of infection control precautions. Which of the following actions by the AP indicates correct use of the precautions? The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel. Which of the following statements should the nurse make? “If you are unsure about an AP’s ability, observe them performing the task.” A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? Prepare to administer antibiotics to the client A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report? “The client is in the radiology department for a chest x-ray” A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take? Notify the provider about the delayed oxygen tank delivery A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist? “I am worried about taking care of my toddler at home” A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make? “I cannot provide this information to you without your mother’s consent.” A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? A sufficient supply of personal protective equipment A nurse manager is receiving report and is faced with the following situations that require interventions. Which of the following should the nurse manager address first? Three staff members have called to say they will be absent A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? “I will wear a surgical mask within 3 feet of the client.” A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first? Close the documentation program on the computer A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care? Places food on the stronger side of the client’s mouth A home health nurse is assessing an older adult client’s home after providing teaching about home safety. Which of the following actions by the client indicates an understanding of the teaching? The client set the water heater set to 49 degrees Celsius (120 degrees Farhenheit) A charge nurse witnesses an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? Discuss the issue with the A A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients? A client who has a blood pressure of 110/68 mm Hg A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take? Contact the nurse manager A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take? Instruct the AP to discontinue the conversation A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. The client tells the nurse she has decided to go home. Which of the following actions should the nurse take? Have the client sign the Against Medical Advice form A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? Pertussis A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel. Which of the following assessments should the nurse make before delegating care? Has data been collected about specific client needs related to turning? A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? Continue the medication dosages that relieve the client’s pain or Withhold the benzodiazepine but continue the opioid A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? Report the infection to the local health department A nurse is caring for four clients. Which of the following should the nurse assess first? A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? Assessing client needs A nurse is caring a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client’s feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make? “As the health care surrogate, the client’s partner can make this decision.” Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan? Use clean gloves rather than sterile gloves for colostomy care A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? Identify clients who are at risk for falls A nurse manager observes a licensed practical nurse who has a strong odor of alcohol on their breath. Which of the following actions should the nurse manager take? Document an objective description of the situation A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA Include the time the medication error occurred in the report Identify the medication name and dosage administered to the client in the report A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take? Log out so the AP can log in to document the vital signs A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? “I understand, and it’s not too late to change your mind.” A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body? Black A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using? Benchmarking A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include? Institute rounds every 2 hr during the day to offer toileting A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? Whether the client understands the risk of refusing the procedure A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspect's elder abuse. Which of the following actions should the nurse take? Ask the client's son to go to the waiting area A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A client who has peripheral vascular disease and has an absent pulse in the right foot A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has cardiac arrhythmia. Which of the following actions should the nurse take? Proceed with treatment without obtaining written consent A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN? Reinforcing dietary teaching with a client who has heart disease A nurse manager is leading a discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma? A parent wants her 14-year-old adolescent to receive radiation treatment against his will A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information? An evidence-based nursing journal A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? The time the client received his last dose of pain medication or The steps to follow when providing wound care A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is the appropriate procedure for taking care of the client's ring? Place the client's ring in the facility safe A nurse is preparing an educational program for staff members 2 a new intravenous pump. Identify the sequence of actions the nurse should take when developing the program. (Move the steps into the box on the right, placing them in order of performance). 1. Develop learning objectives for the program 2. Determine what skills to teach the staff members 3. Identify resources available to meet objectives 4. Review the staff member's evaluation of the program A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? Social worker A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teachings? "I will have a client who is on airborne precautions wear a mask when out of her room" A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit? A primigravida client who is one day postoperative following a cesarean section and has a PCA pump A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? A client who reports shortness of breath and left shoulder and neck pain or A client who has active bleeding from a puncture wound of the left groin area A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? Physical therapist A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? “I will wear a surgical mask within 3ft of the client” A nurse is supervising assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique? Instructing the client to place her chin toward her chest when swallowing. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care? (SATA) Mental health therapist, nutritionist, occupational therapist A nurse is teaching a newly licensed nurse about client confidentiality. the nurse should include which of the following examples represents a violation of client confidentiality? Informing housekeeping staff that the client is in the dialysis unit A nurse is working on a medical surgical unit and is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? C.A client who has orthostatic hypotension and is receiving IV fluids. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? Determine the reasons the nurses are not taking scheduled breaks A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP? Performing nasal hygiene for a client who has an NG tube A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate? Requesting a referral for the client to attend reminiscence therapy sessions A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report? The name A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising? Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? Using a pain rating scale to monitor a client's pain level A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology? Impaired voluntary cough A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first? Determine the UAP's knowledge about HIV transmission. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? Decreased level of consciousness A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A nurse can recommend clients who are stable for discharge during a disaster. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? Social worker A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include? Close the windows in client rooms A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing? Deep red color on the center of a client's wound A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? Assess the client's understanding of the consequences of uterine prolapse and the need for surgery A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend? Implementing a fall prevention program A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next? Activate the fire alarm A nurse is providing care for a client who is receiving chemotherapy. Which of the following actions should the nurse take? Flush the client's urine down the toilet twice A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first? Client who is confused and has slurred speech A nurse is teaching a group of newly hired nurses about evidence-based practice. The nurse should include which of the following as the first step in the process? Formulate a question A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse? Plan an in-service education program for the unit. A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take? Provide the client with written information in their spoken language. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? My durable power of attorney for health care is part of my advance directives. A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.) Documenting a client's refusal to take a prescribed medication. Providing written information to a client regarding palliative care. Obtaining an interpreter for a client who speaks a different language than the nurse A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? The emergency department nurse is waiting to give report on a new admission. A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel. Ambulate the client. Document the client's urine output. Assist the client with completing their food menu. Obtain the client's vital signs. A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take? Encourage the client to research Crohn's disease on websites that have a.gov address. A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching? Notify me if you observe that the client has distended neck veins. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? The nurse holds her hands above her waist. A nurse is teaching a client about implied consent. Which of the following information should the nurse include in the teaching? Nonverbal behavior indicates agreement. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? An adolescent client whose parents refuse a blood transfusion for religious reasons. A charge nurse is educating a group of newly licensed nurses about the case management approach to client care. Which of the following statements by a newly licensed nurse indicates an understanding of the responsibilities of a nurse in case management? Nurses use critical pathways when caring for clients. A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag? A client who has a compromised airway A charge nurse on a mental health unit is receiving change of shift report for a group of clients. The charge nurse is working with an RN, an LPN, and assistive personnel (AP) from 0700 to 1900 and is reviewing client care assignments. Complete the following sentence by using the lists of options. The charge nurse should first assess the client who has a 7-year history of major depressive disorder, whose friend reports the client has stopped taking their medication, and who is flat, withdrawn, cries all the time, sleeps all the time, and has extremely slowed movements, due to the risk of ? Suicide A newly licensed nurse is floating to an unfamiliar unit and determines that they do not have sufficient experience to safely care for their assigned clients. Which of the following actions should the nurse take? Contact the nurse manager to discuss the situation A nurse manager is a part of a team developing a quality improvement plan to address the increased incidence of central line-related bloodstream infections. Which of the following strategies should the nurse manager include in the plan? Use resources that identify benchmarks of best practices A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department? Gonorrhea A nurse is caring for a client who is having difficulty walking following a stroke. For which of the following members of the interprofessional team should the nurse request a referral? Physical therapist The family members of an older adult client are expressing disagreement over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney. The client is oriented to person, place, and time. Which of the following people has the legal authority to make the care decision? The client A nurse is teaching a group of assistive personnel about airborne precautions. Which of the following statements should the nurse make when caring for a client who has the measles? A respirator should be worn when entering the client's room A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed? A nurse explains to a client's family that a DNR order includes withholding comfort measures A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first? A client who has a neck injury and is unable to breathe spontaneously A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult? Social worker A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary? I need assistance with bathing A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy? State Nurse Practice Act A nurse is reviewing the provider's prescriptions for a client who has a positive sputum culture for tuberculosis. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Collect the client's urine output every 24 hours A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching? Attach the restraints to the fixed portion of the frame of the client's bed A nurse case manager is coordinating care for a client.History and physical: Client has terminal lung cancer and is not expected to live more than 6 months. Select the 3 community resources the nurse should refer the client: hospice, respite care, social worker A nurse suggests respite care for the partner of a client who has mild cognitive impairment.The client's partner asks the nurse how that would help. The nurse should explain that respite care would do which of the following? Allow her to take time off from attending to her partner. A nurse is teaching a newly licensed nurse about telephone prescriptions. Which of the following information should the nurse include? Verify the spelling of the medication with the provider. A nurse is assessing a client's comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure? "I might have to wear a nose clip during this test." A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse? A client who sustained a concussion and is being monitored for complications A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements demonstrate understanding of the procedure? A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP? Perform a simple dressing change for a client A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend? Change peripheral IV primary tubing every 96 hr. A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques? Clean gloves are discarded after removing the old dressing. A nurse implemented a new method of teaching clients about self-administration of insulin six months ago. Which of the following findings indicates the new method is effective? HbA1C numbers decreased A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse use? Critical pathway A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? Notify the provider about the client's concerns. A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse? Elevates the head of the client's bed to 30° before inserting a nasogastric tube A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment? A toddler who cries whenever their parent enters the examination room A nurse is caring for a group of clients on the surgical floor. Which of the following actions should the nurse take to organize their workload and manage time efficiently? Document nursing interventions as they are completed. A nurse is teaching a client about informed consent. Which of the following information should the nurse include in the teaching? The nurse's signature indicates they witnessed the client's signature. A charge nurse witnesses two nurses having a loud discussion at the nurses' station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? Escort the nurses to the nurses' lounge to continue the discussion. A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective? The nurse performs all tasks as specified. A nurse is a member of a quality improvement committee utilizing the Plan-Do-Check-Act (PDCA) model for quality improvement. The nurse should identify evaluation as part of which of the following components of the PDCA model? Check A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? "I can make changes to my living will even after I sign it." A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take first? Observe the client’s condition A client who is unconscious and has extensive internal injuries arrives via ambulance to the emergency department. The staff cannot reach the client's family. Which of the following permits the staff to proceed with emergency surgery? Implied consent While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? Meet with nursing staff to review the policy regarding advance directives. A nurse is caring for a client who requests a copy of their medical records immediately. Which of the following responses should the nurse make? "You must submit a written request before you can receive a copy." A nurse manager is discussing responsibilities of the nurse manager role with a group of newly licensed nurses. Which of the following responsibilities should the nurse include? (Select all that apply.)  Ensure goals of the facility are being met.  Monitor overall functions of the unit.  Make decisions on the unit.  Delegate tasks to assistive personnel.  Reward and discipline staff as necessary. A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure? Documents in the client's record that an incident report was filed A nurse manager is developing a protocol to reduce the incidence of UTIs in clients who have an indwelling urinary catheter. Which of the following interventions should the nurse include in the protocol? Maintain a closed system, ensuring connections are sealed securely. A charge nurse is coordinating a consult with a wound care specialist for a client who has a pressure injury. Which of the following actions should the charge nurse take? Schedule the consultation at a time when the nurse caring for the client can attend. A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure? Documents in the client's record that an incident report was filed A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client refuses to provide a urine sample to check for substance use. Which of the following actions should the nurse take? Document the client's refusal in their chart. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements by a staff nurse indicates understanding? "HIPAA allows clients to request a review of their own medical records." A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client's gait belt was not in place. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Which of the following ethical principles should the charge nurse follow? Veracity A nurse is attending an interprofessional team conference for a client who experienced a stroke. For which of the following findings should the team request a prescription for a referral to the occupational therapist? The client requires assistance getting dressed. A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions? Instruct the client to use the incentive spirometer. A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice? A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? Whether the client understands the risk of refusing the procedure A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Which of the following actions should the nurse take first? Review the intended purpose of the prescribed medications with the client. A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral? The client needs to arrange financial resources to purchase equipment. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I need to tie the restraint to the part of the bed frame that moves. A nurse is reviewing client charts to collect data on the number of urinary catheters that were removed within 48 hours of surgery. This collection of information demonstrates which of the following processes? Outcome audit A nurse is caring for a client who is eligible for a research study. Which of the following should provide informed consent to enroll in the study? Research participant A nurse is preparing to discharge a client from an acute care facility to home. Which of the following information should the nurse plan to include in the client's discharge documentation? Reconciled medications A nurse manager is reviewing the rate of medication errors on a surgical floor and finds that it is 20% above the national average. After setting a standard of care, which of the following actions should the nurse manager take first using the quality improvement process? Observe staff medication administration procedures. A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? Compare practices within the facility against other high-performing facilities. A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first? Measure the client's vital signs. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? The client requires assistance with completing oral hygiene. A nurse is caring for a client who is unresponsive and has advance directives stating they do not want treatment to extend their life. The client's partner is their health care surrogate and requests the nurse begin tube feedings. Which of the following responses should the nurse make? "The client's wishes are to not be given life-saving treatment." A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room? Yankauer suction device A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority? A client who has bipolar disorder and displays constant pacing A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I will wear a cover gown when caring for a client who has herpes simplex." A nurse is assessing a client who has heart failure two months after the implementation of a quality improvement initiative to reduce the hospital readmission rate. Which of the following findings should the nurse identify as an indication the quality improvement initiative is successful? Decreased brain natriuretic peptide levels A nurse case manager is coordinating care for a client. History and PhysicalNurses' Notes Day 1: Client has terminal lung cancer and is not expected to live more than 6 months. Select the 3 community resources the nurse should refer the client.  Respite care  Hospice care  Social worker CASE STUDY A nurse manager is overseeing employees on their unit. Employee Record | Attendance Record 1 month ago Met with employee to discuss recent late arrivals to work. Employee laughs and states, "You would not believe what happened. My dogs got into a fight, and they destroyed my alarm clock. really need to get a new one, but I keep forgetting Discussed expectations for attendance. 2 weeks ago Met with employee to discuss recent concerns by staff members. Employee was found sleeping in the nurse's station and multiple colleagues reported incomplete charting during the employee's shifts. Employee became angry and defensive. Performance improvement plan initiated to address recent behavior at work. Today: Nurse manager called to nurse's station by colleague to attend to the employee Which of the following actions is the nurse manager's priority? Select the action that the nurse manager should take first? Schedule a meeting with the employee to address the occurrence within 24 hr