Nurse Leadership and Management Final Exam - Answered with Rationales

Nurse Leadership and Management Final Exam - Answered with Rationales A nurse is evaluating clients who can be discharged to make room for new clients following a mass causality event. Which of the following clients should the nurse recommend for discharge? A) a client who has pancreatitis and is receiving gastric decompression B) a client who has type 1 diabetes and has positive serum ketones C) a client who is receiving warfarin for a deep vein thrombosis and has an INR of 1.8 D) a client who is receiving chemotherapy and has a platelet count of 10,000/mm3 Rationale: All the rest of the patients are unstable and should not be discharged (platelet count too low, positive ketones, gastric decompression). An INR of 1.8 is within the normal range of 1.5 to 2.0 so this patient is safe to discharge A nurse is teaching an assistive personnel how to clean a bedpan that is soiled with stool infected with clostridium difficile. Which of the following actions by the assistive personnel indicates an understanding of the teaching? A) rinses the stool from the bedpan with hot water B) wear a face shield C) pours a disinfectant into the bedpan containing stool D) Holds the bedpan 30 cm (1 foot) above the toilet when emptying stool Rationale: Stool should be rinsed with cold water due to hot water making stool removal difficult. Stool will inactivate the disinfectant and should be rinsed/removed first. Holding the bedpan high will cause splashing and spread of infection. Wearing a face shield will prevent bacteria exposure when emptying infectious stool A nurse is caring for a group of clients. For which of the following client situations should the nurse complete an incident report? A) Vancomycin was administered 30 mins after the scheduled time B) A digoxin level was drawn 8 hours after the last dose was administered C) a client's family voices concern about the hospital costs D) A client's visitor trips over an IV pump stand Rationale: Giving medication within 30 mins is within the time frame for administration. Digoxin level can be drawn 6-8 hours after administration. Hospital costs should be discussed with a social worker and does not contest an incident report. A nurse enters the room of a client and finds the client lying on the floor. Which of the following actions should the nurse take first? A) call the provider B) ask a staff member for assistance getting the client back in bed C) inspect the client for injuries D) instruct the client to ask for help if they need to get out of bed Rationale: The nurse should always assess the situation first. If the client is injured moving the client can further the injuries. The other options are also important but assessing for injuries should be the priority. An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate for the PN? A) obtain vital signs for a client who is 2 hours post procedure following a cardiac catherization B) Administer a unit of packed red blood cells to a client who has cancer C) Instruct a client who is scheduled for discharge in the performance of wound care D) Develop a plan of care for a newly admitted client who has pneumonia Rationale: PNs are not able to give blood products. PNs cannot perform initial teaching to patients. PNs are able to perform vital signs for patients who are stable. A PN ending their shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take? A) Complete an incident report B) Delegate the task to the PN C) ask the AP if they need assistance D) notify the nurse manager Rationale: An incident report is not necessary. Notifying the nurse manager is not necessary as the nurse can handle the situation. Asking the AP if they need assistance helps to better assess the situation and provide clients with interventions they need A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? SELECT ALL THAT APPLY A) skill proficiency B) assignment to a preceptor C) budgetary principles