ATI Detailed Answer Key meds leadership

l 1. A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? A. "I need to talk to you about unit expectations regarding delegating and completing tasks." B. "Several staff members have commented that you don't do your fair share of the work.". C. "If you don't do your share of the work, I will have to inform the nurse manager." D. "You have been very inconsiderate of others by not completing your share of the work." 2. A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon’s medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? A. Utility B. Paternalism C. Justice D. Nonmaleficence 3. While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? A. Complete an incident report. B. Request the risk manager obtain consent for HIV testing from the client. C. Wash the site of injury with soap and water. D. Consent to postexposure treatment with antiretroviral medications. 4. When planning delegation of tasks to AP a nurse considers the five rights of delegations. Which of the following should the nurse consider when using one of the five rights of delegation? - The AP has the knowledge and skill to perform the tasks 5. A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? - I have to choose a family member as my health proxy 6. A charge nurse has access to the facility’s electronic client records. It is appropriate for the charge nurse to share her personal password with whom? A. The nurse manager B. No one C. A nursing student who is completing a preceptorship on the unit D. The unit clerk 7. A nurse on a medical-surgical unit is reconciling a newly admitted client’s medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. B. The purpose of medication reconciliation is to prevent adverse medication reactions. . C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. . D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility. 8. A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused 9. An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? A. Gather data about the nurse’s work performance and attendance history. B. Approach the involved nurse to discuss the behavior. C. Notify the risk manager. D. Refer the nurse to the board of nursing diversion program. 10. A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client’s family about organ donation. The client’s spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse’s organs." B. "What do you think your spouse would have wanted?" C. "Most religions support organ donation, so don’t let that stand in the way." D. "Don’t you think you will feel a little better about the situation if you donate your spouse’s organs?" 11. A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? A. "If you render aid in an accident, do not leave the scene until another competent person can take over." B. "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse." C. "Federal laws require a licensed nurse to render aid in an emergency." D. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws." 12. A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. B. A staff member does not show up to work her assigned shift. C. A client discovers that his dentures are missing. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing. 13. A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first? A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. B. Report the behavior to the nurse manager. C. Create a written document of the incident and store the document in a safe place. . D. Seek help from a trustworthy friend. 14. A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? A. "I feel you are being inconsiderate of the other team members." B. "I have to let the director of nursing know about this situation." C. "I need to talk to you about the unit policies regarding client assignments." D. "You always get your choice of assignment and don't work your fair share." 15. A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence 16. A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? A. Quietly tell the APs that this is not appropriate. B. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. C. Complete an incident report. D. Document the occurrence in a personal log. 17. A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? A. Take an arterial blood gas (ABG) specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. C. Pass fresh water to clients on the unit. D. Obtain a routine urine sample from a newly-admitted client. 18. A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Justice 19. A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following? A. Ensuring the charge nurse is available to witness the client’s signature on the consent form B. Explaining the risks involved with the procedure C. Discussing alternate treatment options D. Determining the client’s level of understanding about the procedure 20. A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? A. An expert nurse provides testimony that the nurse should have handled the situation differently. B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. C. The client's attorney states that injury to the client could have been prevented. D. The client's provider testifies the nurse was at fault for the injury. 21. A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) A. Provide discharge instructions to a confused client's spouse. B. Obtain vital signs from a client who is 6 hr postoperative. C. Administer a tap-water enema to a client who is preoperative. D. Initiate a plan of care for a client who is postoperative from an appendectomy. E. Catheterize a client who has not voided in 8 hr. 22. A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? A. Ask what she will be assigned to do. B. Determine if she has the skills to complete the assignment. C. Identify her options. D. Notify the nurse manager about her concerns for client safety. 23. A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate? A. “Let’s talk about your concerns about the new policy.” B. “Why didn’t you voice your concerns before the new policy was implemented?” C. “Being open to change is an expectation of the nurses who work on this unit.” D. “You should support this policy change because it was based on evidence-based practice.” 24. A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client’s provider, and completes an incident report, which of the following actions should the nurse take? A. Make a copy of the incident report for the provider. B. Submit the incident report to the risk manager. C. Place the incident report in the client's chart. D. Document in the chart that an incidence report has been filed. 25. A nurse in a provider’s office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse? A. BUN 15 mg/dL B. Platelet count 60,000/mm3 C. WBC 6,000/mm3 D. Hemoglobin 14 g/dL 26. A coworker puts an arm around a nurse and says, “I bet you are a great lover.” Speaking to me like that makes me uncomfortable 27. A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments Transporting a school-age client who is in traction to another department 28. A nurse is working with an assitive personnel to care for a group of clients on the pediatric unit. Which Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a clef t palate 29. . Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? - A young adult client who has crown’s disease and is 1 day preoperative for an ileostomy. 30. A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client’s consent form. Confirms the client appears competent to provide consent 31. A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enemy." Which of the following nursing actions is appropriate at this time? Check the clients medical record for the providers prescription 32. A nurse on a medical-surgical unit is preparing to contact a provider about a client’s condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client’s postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client’s oxygen saturation level and heart rate in which component of the SBAR report? A. Situation B. Background C. Assessment D. Recommendation 33. A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? A. Wound drainage for culture B. Urine from an indwelling catheter C. Blood for PaCO2 D. Random stool specimen 34. A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? A. Keeping an appointment with a client B. Allowing a new mother to hold her stillborn infant C. Confirming that a client going for surgery has signed a consent form D. Refusing to disclose information about a client to the media 35. A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? A. Preventing cross-contamination of clients B. Performing concise client assessment C. Transferring a client to the discharge location D. Maintaining a client tracking system 36. A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? A. Euphoria B. Rhinorrhea C. Hallucinations D. Dilated pupils 37. A nurse manager is reviewing the admission history of four adults who were admitted to the medic surg unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client’s circumstances? - A dependent adult admitted for the treatment of a spiral fracture. 38. A nurse is caring for a client who has advanced lung cancer. The client’s provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? A. "I will have to be admitted to a long-term care facility in order to receive hospice care." B. "I should expect the hospice team to help me manage my dyspnea." C. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." D. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care." 39. A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities? A. Assessing the current health status of the client B. Explaining the operative procedure, risks, and benefits C. Reviewing preoperative laboratory test results D. Ensuring that a signed surgical consent form was completed 40. A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client’s family. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client’s family is reached C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine 41. An assistive personnel comes to work with a new set of artificial nails. The nurse takes the ap to a private There is a higher risk of infection for our clients associated with artificial nails 42. A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A. An adolescent female client who is belligerent and has slurred speech B. A toddler who has a laceration on his forehead and is screaming C. A middle adult male who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn of his face and arms 43. A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take? A. Pull the curtain around the client's bed. B. Wash the client’s arms and hands first. C. Use a washcloth to wipe the client’s eyes from the outer canthus to the inner canthus. D. Fill the bath basin with tap water that is 39° C (102.2° F). 44. A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) D. Rescue the clients. A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire. 45. A nurse manager has received information from the facility’s risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process? A. Complaint phase B. Discovery phase C. Decision phase D. Trial phase 46. A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? A. "I have my assignment and will start with room 1, then work my way to room 10." Rationale:The AP’s statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized. B. "I will give this client his meal tray first, as he is going early to physical therapy." C. "After breakfast, I will pack the belongings of clients who will be discharged this morning." D. "I will start by providing partial baths before breakfast." 47. A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "The nurse relinquishes accountability for client outcomes when care is delegated to an AP." B. "The AP can provide client education about how to perform basic self-care to the client." C. "The nurse should consider the AP’s level of experience when making delegation decisions." D. "The AP can re-delegate a task to another AP who has similar work experience." 48. A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)? A. "The client’s family members have been present most of the day." B. "The client’s blood pressure and pulse have been fluctuating throughout the day." Rationale:Knowing the client and the stability of his condition is a criterion to consider when delegating to the AP. To promote client safety, the more stable clients should be chosen when delegating tasks to APs. C. "The client discussed having prior thoughts of suicide." D. "The client works in the hospital radiology department." 49. A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? A. Right circumstances. B. Right communication C. Right person D. Right supervision Rationale:The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed. 50. A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? A. A client who needs assistance with a bath B. A client requesting a referral for home health services C. A client asking about his PCA pump that contains morphine D. A client who has questions about his new prescription 51. At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN? A. Providing postmortem care for a client B. Measuring a client’s I&O C. Obtaining a client’s weight D. Inserting a nasogastric tube for a client Rationale:This is an appropriate task to assign to the LPN. It is not appropriate to assign this task to the AP. 52. A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients? A. A child who is experiencing sickle cell crisis B. A child who has streptococcal pharyngitis C. A child who has a head injury D. A child who has a new diagnosis of type 1 diabetes mellitus Rationale:The nurse should place these clients together. It is appropriate because the child who has diabetes requires monitoring and teaching and the child who is postoperative from an appendectomy requires frequent assessments and interventions. 53. A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program? A. Proper foot care will be demonstrated to clients during the program. B. Clients will have a decreased incidence of foot amputations. Rationale:A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program. C. A facility will be reserved for the program. D. Handouts and teaching materials will be distributed at the program. 54. An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? A. The client who requires frequent ambulation B. The client who is in protective isolation C. The client who is actively dying and requires IV pain medication Rationale:The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family. D. The client who is 3 days postoperative and requires a dressing change 55. A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take? A. Verify the AP’s educational preparation prior to delegating the task. B. Determine the time frame the AP should report the results. C. Observe the AP as she obtains the vital signs of each client. D. Ask the AP to take the vital signs of the client returning from surgery first. 56. An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN Rationale:According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation 57. A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take? A. Inform the staff member of her appraisal time for that day prior to change-of-shift report. B. Schedule the appraisal interview as early in the shift as possible. C. Provide a chair directly across the desk for the staff member to sit in. D. Provide the staff member with a copy of the appraisal form in advance. Rationale:The charge nurse should ensure the staff member knows the standards by which her work will be evaluated and that she has a copy of the appraisal form. 58. A nurse is planning to assign care terminal to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.) A. Accompany a client who has depression to occupational therapy. B. Assess a client who has hypomania for exhaustion. C. Check the position of a client in sof t wrist restraints. D. Set limits with a client who has mania. E. Sit with a client who has alcohol use disorder and whose last drink was five days ago. 59. .A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? A. Discussing advance directives with the client and the client's family B. Providing comfort care measures to the client C. Withholding a dose of narcotic pain medication when the client has respiratory depression Rationale:The principle of nonmaleficence is an obligation not to inflict harm. It is customary to ease a client's pain via the administration of narcotics. However, if the nurse believes the dose is potentially lethal or could hasten the client's death, the nurse should not administer the medication on the grounds of nonmaleficence. D. Allowing the client's family unlimited visitation at the time of death 60. A charge nurse is working with an assistive personnel (AP) who provides excellent care to client and is an effective team member. Which of the following actions should the nurse take first to recognize the AP’s contributions to client care? a. Detail the AP’s contribution to the nurse manager b. Tell other nurses what an effective team member the AP is. c. Give positive feedback directly to the AP d. Nominate the AP for the Employee of the month reward. 61. A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight B. A client who has terminal cancer and needs assistance with pain management Rationale:A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea. C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work D. A client who has dementia and needs help with activities of daily living 62. A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client’s rights and is an example of which of the following? A. Slander B. Invasion of privacy C. Defamation of character D. False imprisonment Rationale:Unlawfully restraining a client is false imprisonment. Clients have the right to refuse treatment. 63. A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.) A. Demonstrate the technique to instill eye drops. B. Ambulate a client who has a cane. C. Irrigate a wound. D. Transfer a client to a stretcher. E. Record urinary output. 64. A nurse is planning care for four clients and is assigning task to LPN and an AP. Which of the following should the nurse assign to the LPN? - Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. 65. A nurse on a med surg unit has accepted a transfer to the ICU. Prior to transfer to ICU, the nurse completes online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles? - nonmaleficence 66. A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? A. "The client should be seen by a neurologist." B. "The client was found unconscious on the floor in her home." C. "There are no provider’s prescriptions available." D. "The client is disoriented. Pupils are slow to respond to light." 67. A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider? A. The most experienced nurse receives the more complex clients B. Personal comfort level in making the assignments C. Social relationships between nurses working the oncoming shift D. The physiologic status of the clients on the unit 68. A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? A. Assigning two assistive personnel (AP) to ambulate all clients B. Assigning a new graduate nurse to perform a wet-to-dry dressing change C. Assigning the most efficient AP to perform glucometer monitoring for each client D. Assigning the most competent RN to perform a central line dressing change 69. A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)? A. Developing the plan of care for a client who has an amputation B. Evaluating the outcomes of a new postoperative client C. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus D. Assisting a client with crutch walking following knee replacement surgery 70. A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take? A. Focus on providing care that prevents life-threatening emergencies. B. Reinforce discharge teaching to clients. C. Instruct the assistive personnel (AP) to focus on clients’ ADLs. D. Stock additional unit supplies. 71. A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)? A. Application of antibiotic ointment to the arm of a client who has dermatitis B. Obtaining medical history information from a stable client who is being admitted C. Monitoring vital signs of a client who had an appendectomy 12 hr ago D. Removal of the nasogastric tube of a client who has been receiving enteral feedings 72. A nurse is assessing four clients on a med surg unit. Which of the following clients should nurse care for first? - A client who has a cast on the lef t leg and reports numbness and paresthesia 73. A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients? A. A client who is 1 hr postoperative following a thyroidectomy B. A client who is 2 hr postoperative following an abdominal hysterectomy C. A client who is 3 days postoperative following gastric bypass surgery Rationale:The client’s physiologic status and stability of vital signs are considerations when assigning vital signs to an AP. This client is 3 days postoperative and his condition would have stabilized by this time. D. A client who is 3 days postoperative following a craniotomy 74. A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN? A. The state Nurse Practice Act B. The National Association for Practical Nurse Education and Services C. The National Council of State Boards of Nursing Decision Tree D. The Omnibus Budget Reconciliation Act of 1987 75. A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client’s dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take? a. Report the issue to the unit manager b. Change the client’s dressing c. Reassigns the tasks to another nurse. d. Verify the LPN knows how to do a dressing charge. 76. A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform? A. Administration of an enema B. Application of antiembolic stockings C. Assessing a client’s sacrum for edema D. Assisting a client to cough and deep breathe 77. A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first? A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. B. Apply a condom catheter to a client who is incontinent. C. Feed a client who has bilateral casts due to upper arm fractures. D. Deliver a clean voided urine specimen to the laboratory. 78. A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation? A. "Delegation provides appropriate resources for the client." B. "Delegation permits a designated individual to meet a goal on your behalf." C. "Delegation promotes discharge teaching activities for clients." D. "Delegation decreases health care costs." 79. A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement? A. Sit in front of the group for the meeting and then stand for the announcement. B. Cross her arms over her chest when beginning the announcement. C. Stare at the people the announcement will affect the most. D. Lean gently over the back of a chair sitting to one side of the room when making the announcement. 80. A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form? A. Extended family B. Blended family C. Nuclear family D. Intergenerational family 81. A nurse enters a client’s room and finds the client pulseless. The family has requested a do-not- resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A. Call the emergency response team. B. Seek immediate help from the risk manager C. Call the provider for a stat DNR order. D. Respect the family’s wishes and do nothing. 82. A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP? A. A client who has a lumbosacral spinal tumor B. A client who has Guillain-Barre syndrome C. A client who has amyotrophic lateral sclerosis (ALS) D. A client who has systemic sclerosis 83. A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take? A. Assess the AP’s ability to follow the client’s teaching plan. B. Determine the social skills of the AP. C. Evaluate the ability of the AP to work with peers. D. Provide a clear description of the task to the AP. 84. A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? A. Assault Rationale:Assault is the act of verbally threatening a client. A nurse who verbally threatens to give a medication to a client without the client’s consent is committing assault. B. False imprisonment Rationale:False imprisonment is detaining a client against her will without legal warrant. A nurse who administers a chemical restraint without the client’s consent is committing false imprisonment. C. Negligence Rationale:Negligence is a breach of duty that results in harm to the client. A nurse who administers an incorrect medication to a client is committing professional negligence. D. Battery Rationale:Battery is physical contact without the client’s consent. Administering a medication against a client’s wishes is an example of battery. 85. A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.) A. Establish that the client is able to pay for the surgical procedure. B. Explain the surgical procedure to the client. C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary. 86. A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? A. Members of the Federal Emergency Management Agency (FEMA) B. Responding law enforcement officers C. Representatives from the American Red Cross D. Nurses and other emergency medical personnel 87. A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness? A. "I feel as though I met the standard of care. Would you tell me more about your concerns?" B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I am at a loss for words. I always do my best to give good care to my clients." D. "What do you have against me? It must be something or you wouldn't be criticizing my care." 88. A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence? A. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. B. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. C. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips. 89. A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management? A. Avoiding B. Competing C. Compromising D. Cooperating 90. A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "I should wait to empty my client’s drainable colostomy until it is three-fourths full." B. "I should delegate providing closed irrigation to the assistive personnel (AP)." C. "I should encourage clients to receive an annual flu immunization." D. "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care." 91. A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents? A. Chemical Rationale:The emergency department nurse should be prepared for a client following exposure to chemical agents; however, this type of agent is not referred to as a "dirty bomb." B. Anthrax Rationale:Anthrax is a bacterium that is used in bioterrorism. It is not included in a "dirty bomb." C. Radiologic Rationale:A "dirty bomb" combines radiologic agents with an explosive device, resulting in immediate effects of radiation exposure. D. Sarin Rationale:Sarin is a gas that affects the central nervous system. It is not included in a "dirty bomb." 92. A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? A. Vigorously rub the skin following a decontamination shower. B. Initiate seizure precautions. C. Provide respiratory support with a plastic oral airway. D. Prepare to administer amyl nitrate. 93. A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A. A client who has a punctured femoral artery B. A client who has multiple fractures C. A client who has a red rash over his abdomen D. A client who reports severe flank pain radiating to the groin 94. A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager? A. Ask other staff nurses about the level of care the specific staff nurse provides. B. Address the concern with the specific staff nurse. C. Recommend the specific staff nurse be transferred to another unit. D. Notify the human resources department about the request. 95. A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) A. The date of the incident B. The name of the provider who prescribed the medication C. The potential adverse effects of the medication D. The time the client was to receive the medication E. The client's vital signs 96. A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? A. The client's partner B. The client Rationale:If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent. C. The client's daughter, who is the primary caregiver D. The client's son, who has a durable power of attorney 97. A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? a. The nurse uses the client’s telephone number as one form of identification when administering medications to a client. b. The nurse uses clean gloves when discontinuing a client’s intravenous infusion. c. The nurse empties a client drainable colostomy pouch when it is one third full. d. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. 98. A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? A. Counsel the provider to determine the cause of the substance abuse. B. Encourage clients to change to a different provider. C. Inform the state medical board for an immediate investigation. D. Notify the nursing supervisor of the concerns. 99. A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? A. Encourage the client to verbalize questions. B. Insist the client take prescribed medications. C. Inform the client that the medication is the same as taken at home. D. Tell the client that refusal of the medication is considered noncompliance. 100. A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) A. Raise all side rails on the client's bed. B. Obtain a prescription to restrain the client PRN. C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg.