kaplan management of care A NGN

30 flashcards

the nurse manager discusses that certain workers may be at greater r/f latex allergies than others. after reviewing the medical histories of the nurses on the unit, the nurse manager determines which nurse can safely use latex products? a. the nurse w a history of allergens to pollen and grass b. the nurse with a history of allergies to banana and kiwi c. the nurse with a history of multiple surgeries d. the nurse w a history of GI upset

d. the nurse with a history of GI upset a. any history of allergies indicates a greater r/f latex allergies.b. a history of food allergies indicates an individual is at greater r/f latex allergies (nvm that the allergy listed is specific to tropical fruits, which is the greatest indicator)c. individuals who have had numerous surgeries and therefore numerous opportunities to repeated exposure to latex are at greater r/f latex allergies

which change strategy is most likely to be used by nurse managers who believe people are rational and will act in ways that will be in their own best interest? a. empirical-rational strategies b. power-coercive strategies c. normative--re-educative strategies d. historical-futuristic strategies

a. empirical-reductive strategiesbased on the idea ppl are rational and will act in ways they intellectually understand will be in their own best interest b. power-coercive strategies are based on the use of power to cause change, most often in the direction of having less powerful ppl conform to plans and directives of the more powerful. it may also go in the opposite direction, s/a when employees strike and thereby exert their own power to create changec. normative--re-educative strategies include the empirical-rational idea, but include the importance of attitudes and values. in addition to giving information, attention is paid to attitudes, values, skills, and relationships. there is considerable focus on individuals as the basic unit of social organizationd. historical and futuristic ideas may be particularly useful underpinnings for empirical-rational strategies

the nurse provides care for pts in a gynecologic clinic. which pt does the nurse see first? a. a middle-age pt reporting a dry vaginal wall and painful intercourse b. an adult pt who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash c. an adult pt preparing for a cervical biopsy who reports feeling highly anxious d. a young adult pt scheduled for a pap smear who reports heavy bleeding w menstruation

b. an adult pt who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rashallergic rxn s/s a. findings not unusual given agec. not require immediate attentiond. also not important

the nurse understands which is a primary focus of the NCLEX-RN? SATA a. performance appraisal b. evaluation of nursing schools c. assessment of minimum competency d. determination of ability of entry level nurse to perform safelye. measurement of quality pt care

C + D

the nurse begins employment in a hospital using the SOAP system of documentation. the nurse understands SOAP is an acronym for which information? a. strategic, operational, accountability, protocol b. status, orders, actions, precautions c. secure, orderly, appropriate, precise d. subjective, objective, assessment, plan

d. subjective, objective, assessment, plan the rest aren't right, though b might not be bad for report...

the nurse manager observes the response of several staff to change which occurs on the med-surg unit. the staff are classified as "early adopters" if which behavioral pattern is observed? a. the staff are open and receptive to new ideas and are sought out by others b. the staff thrive on change and see it as an exciting adventure which can advance their careers c. the staff are not the first to accept a change, nor are they the last d. the staff are openly negative about changes and adopt them only after most others have done so

a. the staff are open and receptive to new ideas and are sought out by others-early adopters are open and receptive to new ideas. peers tend to respect them and seek them out for information and advice about proposed or implemented changes b. this describes "innovators," who are enthusiastic and energetic about change, possibly to the point of seeking it out and being disruptive to unit stabilityc. "early majority" people have a preference for the status quo. however, they will accept new ideas eventually, usually before the average person has done so. the listing of behavioral patterns in response to change proceeds from quickest to slowest to adopt: innovators, early adopters, early majority, late majority, laggards, rejectorsd. "late majority" they are skeptical about change, express their negativity openly, and only adopt change once the majority of other people have done so

A nurse manager terminates a nurse for falsifying an entry in a medical record. Several months later, the manager receives a call from an agency asking for a reference for the terminated employee. Which is the nurse manager's most appropriate response to the potential employee? 1. "I will have to consult an attorney before speaking with you." 2. "The nurse did a good job and then resigned." 3. "That employee did work for me and was terminated for poor performance." 4. "I can't speak with you about that employee."

Correct answer: 3. "That employee did work for me and was terminated for poor performance." 1) The nurse manager is potentially liable if the new employer is not warned about employee incompetency or impairment. 2) The potential employer should be given information about the terminated employee. The nurse manager can inform the potential employer that the employee was terminated and that the employee did not perform to the level as was expected. 3) CORRECT – There are no federal laws that address what an employer can or can't say about a worker. Many states, however, have enacted legislation that gives employers a qualified immunity when providing information for a reference check. These statutes generally provide that an employer is immune from civil liability when it responds to a reference check in good faith. The immunity is lost, however, if it can be shown that the employer knowingly or recklessly provided false or misleading information or acted with malicious intent. The manager can freely acknowledge the employee's dates of employment, and that the employee was terminated. The manager should reference the potential employer to the HR department for further information. 4) The manager can acknowledge the dates of employment, that the employee was terminated , and that the potential employer may speak with HR for further information.

The nurse delegates tasks to staff on the night shift. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Begin a blood transfusion on a postoperative client. 2. Change the colostomy bag on a client with an ileostomy. 3. Administer morning insulin to a client on a sliding scale. 4. Obtain a client's daily weight and shift intake and output.

Correct answer: 4. Obtain a client's daily weight and shift intake and output. 1) This is an assignment for the nurse. The nurse must assess this client frequently. The nurse cannot delegate clients who require assessment, teaching, or nursing judgment. Once a transfusion is started, the nurse may assign the LPN/LVN to monitor the client's vital signs. 2) This assignment is within the scope of practice for the LPN/LVN. 3) The LPN/LVN can obtain the blood glucose and administer insulin according to a sliding scale. According to the policy on the unit, the LPN/LVN may need to check the insulin dosage with another nurse. 4) CORRECT – This is a standard, unchanging procedure. The UAPs assist with direct client care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable clients, and stocking supplies.

The nursing team consists of two nurses (RNs), one LPN/LVN, and two unlicensed assistive personnel (UAP). The nurse considers which assignment appropriate for the LPN/LVN to complete? (Select all that apply.) 1. Obtain vital signs for the client immediately after electroconvulsive therapy (ECT). 2. Assist the client who requires bathing and feeding. 3. Administer a tube feeding for the client who has dysphagia. 4. Provide discharge instructions for the client diagnosed with multiple sclerosis. 5. Teach the client how to administer a subcutaneous injection. 6. Change the clean dressing for the client with a venous ulcer.

Correct answers: 3 and 6. 3. Administer a tube feeding for the client who has dysphagia. 6. Change the clean dressing for the client with a venous ulcer. 1. this requires assessment by the nurse. immediately after the procedure, orient the patient, take BP and RR, and stay w the pt during times of confusion. UAP can obtain VS after the pt is alert, oriented, and stable 2. With on LPN/LVN on the team, and two UAPs, this is a more appropriate assignment for the UAP. Assign standard, unchanging procedures 3. CORRECT - this is an appropriate assignment for the LPN/LVN. The nurse will assign stable pts w expected outcomes to the LPN/LVN 4. Providing discharge instructions for a pt diagnosed w multiple sclerosis requires teaching. This is an appropriate activity for the nurse. The nurse cannot delegate assessment, teaching, or nursing judgement. 5. This is an appropriate activity for the nurse. The nurse cannot delegate assessment, teaching, or nursing judgement. 6. CORRECT - this is an appropriate assignment for the LPN/LVN. The nurse will assign stable pts w expected outcomes to the LPN/LVN

Case study: The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. Admission orders: 1. Admit to oncology unit. diagnosis: metastatic breast cancer 2. bilateral mastectomy and placement of left upper chest subcutaneous vascular access port tomorrow at 1000 3. chest x-ray tonight 4. 12-lead ECG tonight 5. NPO after midnight 6. activity: up as tolerated 7. chlorhexidine shower tonight 8. vital signs q 4 hours while awake 8. IV D5NS at 100 mL/hr 9. draw BMP and CBC tonight 10. cefoxitin 1 g IVPB on call to OR 11. metformin 500 mg PO daily in am 12. levothyroxine 25 mcg PO daily in am 13. lorazepam 1 mg PO on call to OR 15. acetaminophen 500 mg PO q 6 hours PRN mild pain (1–3/10) 16. oxycodone/acetaminophen 5/325 mg PO q 6 hours PRN moderate pain (4–6/10) 17. hydromorphone 0.5 mg IVP every 3 hours PRN severe pain (7–10/10). The nurse on the oncology unit prepares to admit the client to the unit and reviews the physician's orders. Select three tasks appropriate to assign to the UAP working with the nurse. Answer Choices: obtaining and recording vital signs every four hours obtaining the 12-lead ECG performing venipuncture to obtain lab work assisting client with chlorhexidine shower as needed answering the client's questions about a subcutaneous venous access device assisting the client to the bathroom as needed assessing the client's pain obtaining the client's signature on the surgical consent.

Correct tasks: assisting the client to the bathroom as needed assisting client with chlorhexidine shower as needed obtaining and recording vital signs every four hours. The UAP may assist the client with activities such as bathing, eating, or ambulating to the bathroom. The UAP may also obtain and record a client's vital signs and will report any findings outside of normal parameters to the RN. The nurse may not delegate certain activities to the UAP. Obtaining an ECG is done by a nurse or by a technician. It might be performed by a UAP but only with specific training. Venipuncture is a nursing responsibility. Providing education and answering the client's questions must be performed by the RN, as is assessment of the client's pain. It is the responsibility of the surgeon to obtain the client's consent for surgery.

The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. MAR: (key: (A) administered, (H) held, (U) unavailable Scheduled meds: metformin 500 mg PO daily in AM - 0700 (H) levothyroxine 25 mcg PO daily in AM - 0700 (A) D5NS at 100 mL/h - 150 mL remained; 0730 (A) Lorazepam 1 mg PO on call to OR Cefoxitin 1 g IVPB on call to OR PRN meds: albuterol 1 unit dose via nebulizer q8h PRN for dyspnea APAP 500 mg PO q6h PRN mild pain (1-3/10) oxy/APAP 5-325 mg PO q6h PRN moderate pain (4-6/10) hydromorphone 0.5 mg IVP q3h PRN severe pain (7-10/10) On the morning of surgery, the nurse reviews the physician's orders that were written the night before surgery, checks the client's medication administration record (MAR), and completes an assessment of the client. Identify the data indicating the client may be experiencing anxiety. 1. BP 156/94, HR 117. 2. RR 18, SpO2 (on room air) 95%. 3. Client oriented to person, place, time, and situation. 4. Client asks repeatedly, "What time is it now?" 5. Abdomen soft with (+) bowel sounds x 4. 6. Client denies hunger, but states, "My stomach is in knots." 7. Lungs are clear but diminished throughout. 8. Client pleasant but tearful throughout assessment. 9. Client states, "I'm afraid. I'm really terrified." 10. Client states, "I just wish the doctor would get here so I can sign the papers and get it over with."

Correct findings: 1, 4, 6, 8, 9, and 10. 1. BP 156/94, HR 117. 4. Client asks repeatedly, "What time is it now?" 6. Client denies hunger, but states, "My stomach is in knots." 8. Client pleasant but tearful throughout assessment. 9. Client states, "I'm afraid. I'm really terrified." 10. Client states, "I just wish the doctor would get here so I can sign the papers and get it over with." The client's anxiety is exhibited in subjective and/or objective assessment data. Elevated heart rate and elevated blood pressure (in the absence of diagnosed hypertension) are objective indicators that the client is having physical manifestations of increased stress and sympathetic stimulation. Reports of stomach upset or distress may also indicate anxiety. Repeating questions, being tearful or emotional, and making statements such as being "terrified" and wanting to "get it over with" are subjective findings for anxiety. The other assessment findings are within normal limits and do not indicate the client is experiencing anxiety.

The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. Identify the appropriate nursing response to the client's anxiety. SATA 1. Continue to encourage client to share concerns. 2. Notify operating room (OR) of a likely delay or cancellation of the client's surgery. 3. Document the client's statements in the medical record. 4. Reassure the client by sharing the surgeon's online satisfaction ratings. 5. Obtain the consent for surgery and answer all client questions about the procedure. 6. Administer lorazepam 1 mg PO now. 7. Contact the client's surgeon and communicate the client's concerns. 8. Contact the hospital chaplain to come and sit with the client.

Correct answers: 1, 3, and 7. 1. Continue to encourage client to share concerns; 3. Document the client's statements; 7. Contact the surgeon and communicate the concerns. Appropriate: It is appropriate for the nurse to address the situation by using therapeutic communication techniques. The nurse will encourage the client to continue to share feelings and concerns to determine the source of the client's anxiety. For a client having a mastectomy, there are numerous factors contributing to the client's fear. The nurse will avoid naming the client's emotions or inferring information from the client's statements and will document what the client states in quotations. The nurse will contact the surgeon and provide information about the client's mounting anxiety and ask an approximate time the surgeon anticipates seeing the client. Inappropriate: It is inappropriate for the nurse to notify the OR of a potential delay or cancellation. Obtaining the consent forms and discussing the procedure is the responsibility of the surgeon. Sharing online ratings of any health care professional and/or contacting spiritual care before asking the client are all inappropriate interventions. The lorazepam was ordered to be administered when the client is on call to the OR. Administering it now would violate the prescribed timing.

Case study: The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. When the client's spouse arrives, the spouse states, "Just give me the consent forms, and I will sign them because I am her durable power of attorney for health care." > For each situation, choose the associated ethical principle: Beneficence, Autonomy, or Justice. 1. The nurse sits down with the client and encourages the client to share concerns and feelings. 2. The nurse manager ensures the nurse's other assigned clients receive ordered care while the nurse is working with the anxious client. 3. The nurse recognizes the client has the right to make health care decisions for self, including surgery.

Correct matches: 1. Beneficence. 2. Justice. 3. Autonomy. Beneficence: The duty to act to benefit or promote the good of others (e.g., spending extra time to help calm an anxious client). Autonomy: Respecting the rights of clients to make their own decisions (e.g., acknowledging the client's right to refuse medication or treatment). Justice: The duty to distribute resources or care equally, regardless of clients' personal attributes (e.g., the nurse manager ensures the nurses have needed resources to provide competent care. The nurse devotes equal attention to each client based on acuity of need. One client does not receive preferential treatment at the expense of others).

Case study: The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. The surgeon visits and obtains signed consent from the client. Once the surgeon has left the room, the client's spouse states to the nurse, "She was worried about dying! You need to explain to her that people don't die during surgery anymore." > Which 2 statements are appropriate for the nurse to make to the client? 1. "That's right. This hospital has a very high surgical success rate." 2. "You made a good choice selecting your surgeon." 3. "I can't tell you that, but I can say that the health care team will do everything possible to keep you safe." 4. "What else can I do to help you as you wait to be taken to the preoperative area?" 5. "I think your spouse should go to the cafeteria. Maybe you should ask a different family member to come in." 6. "I've worked here for four years and in all that time, there have only been a few clients with really bad outcomes."

Correct answers: 3 and 4. 3. "I can't tell you that, but I can say that the health care team will do everything possible to keep you safe." 4. "What else can I do to help you as you wait to be taken to the preoperative area?" Therapeutic communication requires the nurse to use honesty and a direct, non-confrontational approach without providing false reassurance. The nurse is unable to promise that there will be no complications but assures the client that the health care team is competent, capable, and will do everything possible to ensure safety. It is also not therapeutic to avoid answering the client's question by providing data on the hospital and/or surgeon, and the client is not concerned with how many clients the nurse has seen with "really bad outcomes." Finally, dismissing the client's spouse or suggesting someone else come in, potentially removes the client's support system.

Case study: The nurse provides care for an older adult client diagnosed with metastatic breast cancer and scheduled for a bilateral mastectomy and placement of an implanted subcutaneous vascular port. Once the client is taken to the preoperative area, the unit nurse documents the interactions with the client and the spouse. > For each medical record entry below, specify whether the entry is appropriate or inappropriate. 1. "Client and the client's spouse fighting all morning." 2. "Client's spouse approached the nurse in the hallway and asked to sign consent forms for the client." 3. "Client's spouse asked the nurse to minimize the physical risks of surgery, including death, to the client." 4. "Client is acting very emotional about surgery, which may be an attempt to gain attention from the spouse."

Correct classifications: 1. Inappropriate. 2. Appropriate. 3. Appropriate. 4. Inappropriate. Documentation must be based on facts and accurate statements provided in context to the situation. It is appropriate for the nurse to include the entries regarding the spouse's actions and statements but inappropriate to include those that are based on conjecture, supposition, and judgment.

The nurse sees clients in the adolescent psychiatric clinic. Which client does the nurse see first? 1. The school age client who reports impulsivity and poor attention span. 2. The adolescent client who displays frequent loss of temper and argues with teachers. 3. The adolescent client who wants to be a model and only drinks water and eats vegetables. 4. The adolescent client who bullies, threatens, and intimidates others and frequently initiates physical fights. Kaplan Management of Care Q7–30 Practice questions transcribed from supplied Kaplan screenshots

Correct answer: 3. The adolescent client who wants to be a model and only drinks water and eats vegetables. 1) This client is displaying attention deficit disorder. The behaviors are not an immediate concern. 2) The client is displaying oppositional-defiant disorder. The client has a potential to hurt others and will need further assessment. 3) CORRECT – This client is the most unstable with actual behaviors that could cause physical harm. The nurse should assess nutritional status and monitor for an eating disorder. 4) This client would be the second client to be seen. The behaviors suggest a more immediate potential to harm others. The nurse will assess for conduct disorder.

Kaplan question 17 The home health nurse is concerned about the large number of clients who are receiving home visits even though they no longer need skilled nursing or therapy services. The nurse discusses these concerns with the management of the agency, but no changes are made. Which would protect the nurse from termination if the nurse reports the agency to regulatory authorities? 1. Title VII of the Civil Rights Act of 1964. 2. Whistleblower Laws. 3. Occupational Health and Safety Act. 4. Family and Medical Leave Act. Kaplan Management of Care Q7–30 Practice questions transcribed from supplied Kaplan screenshots

Correct answer: 2. Whistleblower Laws. 1) This law makes it illegal to discriminate against someone on the basis of race, color, religion, national origin, or sex. 2) CORRECT – Whistleblower laws are intended to prevent employers from taking retaliatory action against nurses such as suspension, demotion, harassment or discharge for reporting improper patient care or business practices. The whistleblower laws vary from state to state and according to the subject matter. 3) Employers covered by the Occupational Health and Safety Act must comply with the regulations and the safety and health standards promulgated by the Occupational Health and Safety Administration. Employers also have a general duty under the act to provide their employees with work and a workplace free from recognized, serious hazards. 4) The Family and Medical Leave Act (FMLA) requires employers of 50 or more employees to give up to 12 weeks of unpaid, job- protected leave to eligible employees for the birth or adoption of a child or for the serious illness of the employee or a spouse, child or parent.

The psychiatric nurse is presented with a group of clients in the emergency department. Which client requires immediate attention? 1. A young adult client who failed medical school and says, "My pain will be over soon." 2. An adult client who is unable to talk in front of other people due to symptoms of anxiety. 3. A middle-age client who hears voices saying the hospital food is poisoned. 4. A middle-age client who is anxious after witnessing a murder.

Correct answer: 1. A young adult client who failed medical school and says, "My pain will be over soon." 1) CORRECT – This client is indicating thoughts of suicide and is at immediate risk for self-harm. The nurse must determine if the client has the means to inflict self-harm. The nurse should place the client on one-to-one observation and stay with client to help control self-destructive impulses. 2) This client does not require immediate attention. The indications of anxiety include increased pulse, increased blood pressure, and increased respirations. The client may also exhibit perspiring and flushing and describe heat sensations. 3) This client does not require immediate attention. The hallucinations the client is experiencing do not pose an immediate risk of harm to self or others. 4) This client does not require immediate attention. The client may be experiencing post-traumatic stress syndrome.

The nurse cares for a client with a managed care plan of insurance. Which is correct about managed care? 1. The client may only use certain approved providers. 2. The client has unlimited coverage for all services prescribed. 3. The client may have services without prior authorization. 4. The client may select any provider the client desires to provide care.

Correct answer: 1. The client may only use certain approved providers. 1) CORRECT – Use of health care providers and services is limited to those within the group who agree to certain fee schedules. Monitoring medical usage is critical in managed care. 2) Cost containment is crucial to managed care. Covered services are restricted to those approved by the managed care provider. 3) Services and providers must be pre-authorized in order to be covered. There may be a medical review to determine necessity. 4) Use of health care providers is limited to those within the network who agree to the allowed payment schedule.

The nurse evaluates clients in the gastrointestinal clinic. Which client does the nurse see first? 1. A middle-age client diagnosed with irritable bowel syndrome reports cramping and loose stools. 2. A young adult client reports not having a bowel movement in 2 days. 3. A school-age client diagnosed with gastroenteritis who had five diarrheal stools in the last 3 days. 4. A newborn client experiencing projectile vomiting and irritability.

Correct answer: 4. A newborn client experiencing projectile vomiting and irritability. 1) The client is experiencing symptoms of irritable bowel syndrome. The nurse should encourage the client to eat meals at regular intervals, chew food slowly, and avoid drinking fluids with meals. 2) The client may be constipated. The nurse should determine the client's normal bowel pattern and encourage fluids and foods high in roughage. 3) This is the second client the nurse should see. The client does not require immediate attention but a child with frequent diarrhea stools has the potential for dehydration. Real problems take priority over potential problems. 4) CORRECT – The client's symptoms indicates pyloric stenosis. The infant is at risk for fluid and electrolyte imbalance and requires immediate intervention.

The nurse moves to a different state and reviews the Nurse Practice Act (NPA) for the state. The nurse understands which governing body enforces the rules of the NPA? 1. American Nursing Association (ANA). 2. National Council of State Boards of Nursing (NCSBN). 3. State Board of Nursing (BON). 4. State Nursing Association.

Correct answer: 3. State Board of Nursing (BON). 1) The American Nurses Association (ANA) is a nonprofit professional organization developed to advance and protect the profession of nursing. The ANA is responsible for establishing standards of nursing practice, promoting the rights of nurses in the workplace, and advancing the economic and general welfare of nurses. 2) The National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which nursing regulatory bodies act and counsel together on matters of common interest and concern affecting public health, safety and welfare, including the development of nursing licensure examinations. The code of ethics lists of the values and standards of conduct of a profession, serving to guide practice and decision-making. It deals with the rightness and wrongness of actions. Violation of a code of ethics can result in disciplinary action by the state board of nursing on the basis of not acting professionally. 3) CORRECT – Each state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA. An NPA is enacted by state legislation and its purpose is to govern and guide nursing practice within that state. An NPA is actually a law and must be adhered to as law. 4) State nursing associations can provide timely and helpful information on nursing issues and policies in the state where the nurse are works. They also provide access to local educational conferences, networking opportunities, and job searches.

Ten clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the emergency department (ED). Which client does the nurse see first? 1. A client with ecchymosis and lacerations to the forehead. 2. A client who reports chest tightness and pressure. 3. A client with a blood pressure of 80/60 mmHg and apical pulse of 130/minute. 4. A client who reports dizziness and nervousness.

Correct answer: 3. A client with a blood pressure of 80/60 mmHg and apical pulse of 130/minute. 1) A client with ecchymosis and lacerations to the forehead. Stable. This client does not require immediate attention. Eliminate. 2) A client who reports chest tightness and pressure. Unstable, unexpected, circulation, potential issue. This client may be experiencing a potential circulation issue, such as an MI, or injuries from the motor vehicle crash, such as seat belt or airbag injury. This client would be seen second. Eliminate. 3) CORRECT – A client with a blood pressure of 80/60 mmHg and apical pulse of 130/minute. Unstable, unexpected, circulation/breathing, actual issue. The vital signs indicate shock. This is the most unstable client. Keep. 4) A client who reports dizziness and nervousness. Stable. Using Maslow's hierarchy of needs theory to prioritize client problems. physiological needs take priority. Actual problems require intervention before potential problems. Eliminate.

A client in an outpatient psychiatric clinic tells the nurse, "I'm going to kill my spouse. That will make my life much better." Which mandate must the nurse follow to meet legal nursing responsibility in this scenario? 1. Good Samaritan. 2. Duty to Warn. 3. Confidentiality. 4. Advocacy.

Correct answer: 2. Duty to Warn. 1) Good Samaritan acts or laws exist to provide civil immunity for individuals who give care at the scene of an emergency such as an accident or disaster. For health care providers to be covered, the care they render in such circumstances must be in accordance with the appropriate standards of care. 2) CORRECT – The nurse must warn third parties of potential violence to them by a client. This mandate supersedes client confidentiality and ethics. 3) Confidentiality refers to the ethical obligation of the nurse to protect the personal information of a client. Personal information generally cannot be divulged to third parties without the express consent of the client. Duty to warn supersedes confidentiality. 4) Advocacy is when the nurse represents the client or the community as a client. The nurse acts to protect the rights of the client to be informed and to participate in the decision-making processes regarding health care.

The nurse plans assignments for the day after receiving the night shift's report. Which client does the nurse see first? 1. An adolescent who took 100 mg methylphenidate and has a BP of 160/100 mmHg. 2. A young adult who requires a metered-dose inhaler. 3. A young adult with a short arm cast on the left arm. 4. A middle-age adult diagnosed with hypothyroidism who reports fatigue.

Correct answer: 1. An adolescent who took 100 mg methylphenidate and has a BP of 160/100 mmHg. 1) CORRECT – This is the most unstable client. Methylphenidate is a CNS stimulant used for ADHD. The blood pressure is elevated. Assess the client for restlessness, dilated pupils, tremors, and possible tonic-clonic seizures. 2) The use of an inhaler may be a potential problem, but this is not the priority client. 3) There are no indications of complications with the cast or fracture. Assess the client for complications such as circulatory impairment and peripheral nerve damage. This is not the priority client. The client would be seen second to assess for possible complications of cast placement. 4) Routine monitoring of TSH levels is required for clients with hypothyroidism. This client is stable. Symptoms of hypothyroidism include fatigue, sensitivity to cold, obesity, and weight gain.

The nurse must use critical thinking skills while providing care for a client receiving a blood transfusion. Which is the best example of critical thinking in the care of this client? 1. The nurse reviews the procedure for blood administration. 2. The nurse checks a unit of blood with another nurse. 3. The nurse evaluates changes in the client's vital signs during the procedure. 4. The nurse documents the procedure in the medical record.

Correct answer: 3. The nurse evaluates changes in the client's vital signs during the procedure. 1) Reviewing a procedure prior to implementation of the procedure does not involve problem solving. 2) Completing a procedure is not an example of critical thinking. If the nurse discovers a discrepancy while checking the blood, critical thinking would be used to problem solve. 3) CORRECT – Critical thinking skills involve complex thinking processes and cognitive activities used in problem solving and decision making. Nurses who use the nursing process engage in critical thinking. The nurse assesses the client's vital signs during a blood transfusion to determine normal vs. abnormal, expected vs. unexpected, to then plan care, implement actions, and evaluate the client's response to those actions. 4) Documentation is part of the procedure and does not involve complex thinking and problem solving skills.

The nurse notices a client diagnosed with major depression crying in the day room. The nurse puts a hand over the client's shoulder and states, "Let's talk about it." Which ethical principle describes the nurse's action? 1. Autonomy. 2. Veracity. 3. Nonmaleficence. 4. Beneficence.

Correct answer: 4. Beneficence. 1) Autonomy is the right to choose and freedom to make decisions for oneself. It is accomplished by providing information and supporting client's choices. 2) Veracity is telling the truth completely. Intentionally deceiving a client is a violation of this principle. 3) Nonmaleficence is the principle of "do no harm." It requires nurses to protect clients from danger and to protect clients who cannot protect themselves. 4) CORRECT – Beneficence is an action that promotes good will. This ethical principle requires the nurse to help clients meet all of their needs.

The nurse reviews a client's medical record. The nurse understands which document entry is an example of objective data? 1. "Client reports, 'I feel so anxious'." 2. "Skin of left leg is pale, cool, and dry." 3. "Client reports pain in left leg which worsens with movement." 4. "Client is anxious and defensive."

Correct answer: 2. "Skin of left leg is pale, cool, and dry." 1) Subjective data is information given by the client and reflects feelings and perceptions as well as concerns. It is best documented in the client's own words. 2) CORRECT – Objective data is information that is observable and measurable by healthcare providers. It may add to or validate subjective data that has been given. 3) Subjective data is information given by the client and reflects feelings and perceptions as well as concerns. It is best documented in the client's own words. 4) This is a judgement by the one documenting. It is not measurable and therefore is not objective data. Subjective data is given by the client. "Client states, 'I feel so anxious." is an example of subjective data.

The nurse manager wants to implement a three-day workweek on the nursing schedule. The nurse manager states, "Anyone who agrees to a three day schedule will receive an increase in the hourly rate of pay." The nurse manager is demonstrating which type of power? 1. Reward power. 2. Coercive power. 3. Expert power. 4. Referent power.

Correct answer: 1. Reward power. 1) CORRECT – The basis of reward power is the ability to provide favors or promise money or other benefits. A manager would reward staff with promotions or extra time off. 2) Coercive power derives from fear and the ability to punish. This type of leader uses power to influence staff in order to achieve goals. 3) Expert power derives from the knowledge and skills that one has developed. A nurse instructing a client about how to manage diabetes has expert power. 4) The basis of referent power is the desire of a follower to be like the leader. For example, students would emulate the behavior of nursing instructors and staff nurses.

The nurse overhears the unit secretary tell a joke with sexual overtones to another staff member. The nurse is offended by the sexual nature and language of the joke. Which action does the nurse take first? 1. Immediately document the incident. 2. Immediately report the incident to the supervisor. 3. Immediately inform the unit secretary that the nurse is offended. 4. Immediately file a sexual harassment complaint with human resources.

Correct answer: 3. Immediately inform the unit secretary that the nurse is offended. 1) This is an appropriate action, but not the first action. The nurse should keep thorough records, and not keep the records at work. 2) This is the appropriate chain of command, but first the nurse should inform the unit secretary that the nurse is offended by the joke. 3) CORRECT – The nurse should inform the unit secretary clearly that the sexual nature of the joke is offensive. Sexual harassment is prohibited by Title VII of the Civil Rights Act of 1964 and includes unwelcome sexual conduct such as pressure to participate in sexual activities, making sexual jokes, or sexual gestures. 4) If the unit secretary does not cease offending the nurse, the nurse should talk to the supervisor and should document the incident. If the supervisor does not take appropriate measures to remedy the situation, the nurse should talk with HR.

The RN assesses clients for the day shift. The nursing team includes one RN, two LPN/LVNs, and four unlicensed assistive personnel (UAP). The nurse determines assignments are appropriate if which client is assigned to the UAP? 1. The client diagnosed with Crohn disease requiring a sterile dressing change. 2. The client diagnosed with chronic kidney failure requiring intake and output. 3. The client diagnosed with full thickness burns requiring IV morphine prior to a dressing change. 4. The client diagnosed with cancer of the lung reporting a headache.

Correct answer: 2. The client diagnosed with chronic kidney failure requiring intake and output. 1) Sterile dressing change should be assigned to the LPN/LVN. 2) CORRECT – UAPs assist with direct client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable clients, and stocking supplies). Assign standard, unchanging procedures. Delegation is the reassignment of responsibility for the performance of a job from one person to another; the responsibility for the task is transferred, but the accountability for the process or outcome of the task remains with the delegator. 3) The RN should care for this client, intravenous medication is within the scope and practice of the RN. 4) This client requires a nursing assessment; the RN should care for this client as assessment falls within the scope of practice for the RN.