RN LEADERSHIP ONLINE PRACTICE
2023B
Which5of5the5following5findings5should5the5nurse5identify5require5follow-
up5by5the5provider?5Select5the565findings5that5require5immediate5follow-up.
Exhibit51:
Day51,51715:
Client5is565hr5postoperative5following5abdominal5surgery.5Client5is5resting5and5easily5awa
kened.5Alert5and5oriented5to5person,5place,5and5time.5Incision5has5moderate5amount5of5s
erous5sanguineous5draining5on5dressing.5Abdominal5dressing5is5intact.5States5pain5level5
is5a545on5a505to5105pain5scale.5Bowel5sounds5are5normoactive.5Client5tolerating5sips5of5w
ater.5Urinary5output53205mL5in5last54hr.
Day51,52030:
Nurse5enters5room5client's5room.5Client5is5restless5and5short5of5breath.5Client5rates5pain5
as5an585on5a5scale5of505to510,5saying,
"My5abdomen5hurts5so5bad."5Nurse5notes5dressing5site5has5large5amounts5of5bright5red5
blood.
-Blood5pressure
-Bowel5sounds
-Pain5level
-Respiratory5rate
-Urinary5output
-Heart5rate
-Orientation5status
-Oxygen5saturation5-5ans--
When5analyzing5cues,5the5nurse5should5identify5that5an5increase5in5heart5rate,5respirator
y5rate,5a5pain5level5of585on5a5scale5of505to510,5a5large5amount5of5bright5red5blood5on5the5c
lient's5abdominal5dressing,5along5with5a5decrease5in5blood5pressure5and5oxygenation5sat
uration5are5manifestations5of5hemorrhage.
Therefore,5the5nurse5should5notify5the5client's5provider5of5these5findings5immediately.
A5charge5nurse5is5reviewing5the5plan5of5care5for5a5client5who5has5active5herpes5simplex5l
esions.5Which5of5the5following5interventions5is5appropriate5for5the5plan5of5care?
a.5Admit5the5client5to5a5private5room5with5negative-pressure5airflow.
b.5Wear5a5gown5and5gloves5when5caring5for5the5client.
c.5Have5the5client5wear5a5mask5during5transport.
d.5Wear5a5face5mask5and5eye5protection5when5caring5for5the5client.5-5ans--
b.5Wear5a5gown5and5gloves5when5caring5for5the5client.
,The5nurse5should5use5contact5precautions5when5caring5for5clients5who5have5an5infection
5from5herpes5simplex.5Barriers5with5gloves5and5gowns5are5mandatory.
A5nurse5is5caring5for5several5clients.5Which5of5the5following5actions5should5the5nurse5tak
e5to5maintain5client5confidentiality?
a.5Tell5a5client's5partner5that5the5client's5laboratory5tests5cannot5be5disclosed5without5per
mission.
b.5Ask5the5assistive5personnel5(AP)5to5refer5to5clients5by5room5number5in5public5areas.
c.5Explain5to5a5nursing5student5that5verbal5permission5must5be5obtained5before5using5a5c
lient's5name5in5school5assignments.
d.5Share5information5about5a5client5with
members5after5personal5identification5has5been5provided.5-5ans--
a.5Tell5a5client's5partner5that5the5client's5laboratory5tests5cannot5be5disclosed5without5per
mission.
This5action5by5the5nurse5will5maintain5client5confidentiality.5Providing5a5client's5partner5wi
th5laboratory5results5without5permission5is5unauthorized5disclosure5of5confidential5inform
ation.
A5charge5nurse5is5managing5conflict5with5a5staff5nurse5who5does5not5agree5with5the5clien
t5care5assignment.5Which5of5the5following5statements5example5of5using5the5conflict5resol
ution5strategy5known5as5smoothing?
a.5"Would5you5accept5the5assignment5if5we5reassign5your5client5who5has5total5care5need
s5and5assign5another5client5who5can5provide5more5self-care?"
b.5"Tell5me5what5changes5we5need5to5make5so5that5you'll5feel5comfortable5with5the5assig
nment."
c.5"I5didn't5mean5to5make5you5feel5overwhelmed.5Why5don't5you5look5over5the5assignmen
ts5with5me5and5suggest5changes?"
d.5"You5always5complete5your5work5on5time5and5do5a5great5job.5I5believe5you5can5handle
5the5assignment5well."5-5ans--
d.5"You5always5complete5your5work5on5time5and5do5a5great5job.5I5believe5you5can5handle
5the5assignment5well."
The5charge5nurse5is5using5smoothing5as5a5conflict5resolution5strategy5by5complimenting5
or5focusing5on5shared5ideas5to5reduce5the5emotional5component5of5the5conflict.
A5nurse5manager5is5planning5daily5work5and5activities5for5the5unit.5Which5of5the5following
5actions5is5the5nurse5manager's5priority?
a.5Assign5client5care5to5staff.
b.5Coordinate5staff5breaks.
c.5Organize5daily5meetings5using5an5appointment5book.
d.5Review5long-term5goals5of5the5unit.5-5ans--a.5Assign5client5care5to5staff.
, When5using5the5urgent5vs5nonurgent5approach5to5client5care,5the5nurse5determines5that5t
he5priority5action5is5to5assign5client5care5to5staff.5This5ensures5continuity5of5care5and5that
5clients5receive5prescribed5treatments5in5a5timely5manner.
A5nurse5is5caring5for5a5school-
age5client5who5is5seeking5treatment5for5a5laceration5to5the5right5forearm5that5occurred5du
ring5soccer5practice.5The5client5was5transported5to5the5emergency5department5by5a5frien
d's5parent5and5the5soccer5coach.5The5nurse5should5ensure5that5informed5consent5is5give
n5by5which5of5the5following5people?
a.5The5client
b.5The5friend's5parent
c.5The5client's5guardian
d.5The5soccer5coach5-5ans--c.5The5client's5guardian
The5parent5or5legal5guardian5is5authorized5to5give5consent5for5the5client.
A5client5is5considering5having5a5tubal5ligation5and5reports5being5uncertain5about5if5it5is5th
e5right5thing5to5do.5Which5of5the5following5actions5should5the5nurse5take?
a.5Provide5information5about5alternate5birth5control5methods.
b.5Ask5if5the5client5has5discussed5the5decision5with5their5partner.
c.5Emphasize5the5benefits5of5having5the5procedure.
d.5Discuss5the5client's5feelings5about5the5procedure.5-5ans--
d.5Discuss5the5client's5feelings5about5the5procedure.
The5nurse5should5encourage5the5client5to5discuss5any5feelings5or5concerns5about5the5pr
ocedure.
An5RN5is5assigning5tasks5to5team5members.5Which5of5the5following5tasks5is5appropriate5t
o5delegate5to5a5licensed5practical5nurse5(LPN)?
a.5Complete5a5client's5admission5assessment.
b.5Titrate5the5flow5of5diltiazem5IV5for5a5client5who5is5in5a5hypertensive5crisis.
c.5Develop5a5teaching5plan5for5a5client5who5was5recently5diagnosed5with5diabetes5mellitu
s.
d.5Suction5a5client5who5has5a5chronic5tracheostomy.5-5ans--
d.5Suction5a5client5who5has5a5chronic5tracheostomy.
Suctioning5a5client5who5has5a5tracheostomy5is5within5the5LP's5scope5of5practice.5The5RN
5should5determine5the5LPN's5competency5and5the5stability5of5the5client5when5considering
5delegation5of5this5task.
A5nurse5walks5into5the5nurses'5station5and5sees5several5staff5members5looking5at5the5ele
ctronic5medical5record5for5a5celebrity5client5on5another5unit.5Which5of5the5following5action
s5should5the5nurse5take5first?
2023B
Which5of5the5following5findings5should5the5nurse5identify5require5follow-
up5by5the5provider?5Select5the565findings5that5require5immediate5follow-up.
Exhibit51:
Day51,51715:
Client5is565hr5postoperative5following5abdominal5surgery.5Client5is5resting5and5easily5awa
kened.5Alert5and5oriented5to5person,5place,5and5time.5Incision5has5moderate5amount5of5s
erous5sanguineous5draining5on5dressing.5Abdominal5dressing5is5intact.5States5pain5level5
is5a545on5a505to5105pain5scale.5Bowel5sounds5are5normoactive.5Client5tolerating5sips5of5w
ater.5Urinary5output53205mL5in5last54hr.
Day51,52030:
Nurse5enters5room5client's5room.5Client5is5restless5and5short5of5breath.5Client5rates5pain5
as5an585on5a5scale5of505to510,5saying,
"My5abdomen5hurts5so5bad."5Nurse5notes5dressing5site5has5large5amounts5of5bright5red5
blood.
-Blood5pressure
-Bowel5sounds
-Pain5level
-Respiratory5rate
-Urinary5output
-Heart5rate
-Orientation5status
-Oxygen5saturation5-5ans--
When5analyzing5cues,5the5nurse5should5identify5that5an5increase5in5heart5rate,5respirator
y5rate,5a5pain5level5of585on5a5scale5of505to510,5a5large5amount5of5bright5red5blood5on5the5c
lient's5abdominal5dressing,5along5with5a5decrease5in5blood5pressure5and5oxygenation5sat
uration5are5manifestations5of5hemorrhage.
Therefore,5the5nurse5should5notify5the5client's5provider5of5these5findings5immediately.
A5charge5nurse5is5reviewing5the5plan5of5care5for5a5client5who5has5active5herpes5simplex5l
esions.5Which5of5the5following5interventions5is5appropriate5for5the5plan5of5care?
a.5Admit5the5client5to5a5private5room5with5negative-pressure5airflow.
b.5Wear5a5gown5and5gloves5when5caring5for5the5client.
c.5Have5the5client5wear5a5mask5during5transport.
d.5Wear5a5face5mask5and5eye5protection5when5caring5for5the5client.5-5ans--
b.5Wear5a5gown5and5gloves5when5caring5for5the5client.
,The5nurse5should5use5contact5precautions5when5caring5for5clients5who5have5an5infection
5from5herpes5simplex.5Barriers5with5gloves5and5gowns5are5mandatory.
A5nurse5is5caring5for5several5clients.5Which5of5the5following5actions5should5the5nurse5tak
e5to5maintain5client5confidentiality?
a.5Tell5a5client's5partner5that5the5client's5laboratory5tests5cannot5be5disclosed5without5per
mission.
b.5Ask5the5assistive5personnel5(AP)5to5refer5to5clients5by5room5number5in5public5areas.
c.5Explain5to5a5nursing5student5that5verbal5permission5must5be5obtained5before5using5a5c
lient's5name5in5school5assignments.
d.5Share5information5about5a5client5with
members5after5personal5identification5has5been5provided.5-5ans--
a.5Tell5a5client's5partner5that5the5client's5laboratory5tests5cannot5be5disclosed5without5per
mission.
This5action5by5the5nurse5will5maintain5client5confidentiality.5Providing5a5client's5partner5wi
th5laboratory5results5without5permission5is5unauthorized5disclosure5of5confidential5inform
ation.
A5charge5nurse5is5managing5conflict5with5a5staff5nurse5who5does5not5agree5with5the5clien
t5care5assignment.5Which5of5the5following5statements5example5of5using5the5conflict5resol
ution5strategy5known5as5smoothing?
a.5"Would5you5accept5the5assignment5if5we5reassign5your5client5who5has5total5care5need
s5and5assign5another5client5who5can5provide5more5self-care?"
b.5"Tell5me5what5changes5we5need5to5make5so5that5you'll5feel5comfortable5with5the5assig
nment."
c.5"I5didn't5mean5to5make5you5feel5overwhelmed.5Why5don't5you5look5over5the5assignmen
ts5with5me5and5suggest5changes?"
d.5"You5always5complete5your5work5on5time5and5do5a5great5job.5I5believe5you5can5handle
5the5assignment5well."5-5ans--
d.5"You5always5complete5your5work5on5time5and5do5a5great5job.5I5believe5you5can5handle
5the5assignment5well."
The5charge5nurse5is5using5smoothing5as5a5conflict5resolution5strategy5by5complimenting5
or5focusing5on5shared5ideas5to5reduce5the5emotional5component5of5the5conflict.
A5nurse5manager5is5planning5daily5work5and5activities5for5the5unit.5Which5of5the5following
5actions5is5the5nurse5manager's5priority?
a.5Assign5client5care5to5staff.
b.5Coordinate5staff5breaks.
c.5Organize5daily5meetings5using5an5appointment5book.
d.5Review5long-term5goals5of5the5unit.5-5ans--a.5Assign5client5care5to5staff.
, When5using5the5urgent5vs5nonurgent5approach5to5client5care,5the5nurse5determines5that5t
he5priority5action5is5to5assign5client5care5to5staff.5This5ensures5continuity5of5care5and5that
5clients5receive5prescribed5treatments5in5a5timely5manner.
A5nurse5is5caring5for5a5school-
age5client5who5is5seeking5treatment5for5a5laceration5to5the5right5forearm5that5occurred5du
ring5soccer5practice.5The5client5was5transported5to5the5emergency5department5by5a5frien
d's5parent5and5the5soccer5coach.5The5nurse5should5ensure5that5informed5consent5is5give
n5by5which5of5the5following5people?
a.5The5client
b.5The5friend's5parent
c.5The5client's5guardian
d.5The5soccer5coach5-5ans--c.5The5client's5guardian
The5parent5or5legal5guardian5is5authorized5to5give5consent5for5the5client.
A5client5is5considering5having5a5tubal5ligation5and5reports5being5uncertain5about5if5it5is5th
e5right5thing5to5do.5Which5of5the5following5actions5should5the5nurse5take?
a.5Provide5information5about5alternate5birth5control5methods.
b.5Ask5if5the5client5has5discussed5the5decision5with5their5partner.
c.5Emphasize5the5benefits5of5having5the5procedure.
d.5Discuss5the5client's5feelings5about5the5procedure.5-5ans--
d.5Discuss5the5client's5feelings5about5the5procedure.
The5nurse5should5encourage5the5client5to5discuss5any5feelings5or5concerns5about5the5pr
ocedure.
An5RN5is5assigning5tasks5to5team5members.5Which5of5the5following5tasks5is5appropriate5t
o5delegate5to5a5licensed5practical5nurse5(LPN)?
a.5Complete5a5client's5admission5assessment.
b.5Titrate5the5flow5of5diltiazem5IV5for5a5client5who5is5in5a5hypertensive5crisis.
c.5Develop5a5teaching5plan5for5a5client5who5was5recently5diagnosed5with5diabetes5mellitu
s.
d.5Suction5a5client5who5has5a5chronic5tracheostomy.5-5ans--
d.5Suction5a5client5who5has5a5chronic5tracheostomy.
Suctioning5a5client5who5has5a5tracheostomy5is5within5the5LP's5scope5of5practice.5The5RN
5should5determine5the5LPN's5competency5and5the5stability5of5the5client5when5considering
5delegation5of5this5task.
A5nurse5walks5into5the5nurses'5station5and5sees5several5staff5members5looking5at5the5ele
ctronic5medical5record5for5a5celebrity5client5on5another5unit.5Which5of5the5following5action
s5should5the5nurse5take5first?
