Which of the following change strategies is most likely to be used by nurse managers who consider attitudes, values, and interpersonal relationships to be very important?
An RN assesses clients for the day shift. The nursing team includes one RN, two LPN/LVNs, and four nursing assistants. The nurse determines that assignments are appropriate if which of the following patients is assigned to a nursing assistant?
A patient diagnosed with chronic renal failure requiring intake and output.
The RN has received an assignment for the night shift. Which task is appropriate for the nurse to delegate to a nursing assistive personnel with 20 years of experience?
Bathe a client prior to the scheduled 0600 surgery.
The RN from the pediatric unit is assigned to the psychiatric unit. Which client assignment is the most appropriate for the reassigned nurse?
A client diagnosed with depression with a decreased appetite.
The nursing team caring for clients on the pediatric unit consists of two RNs, two LPN/ LVNs, and two nursing assistive personnel. Which client doe the nurse assign to the LPN/LVN?
A child in a balanced suspension traction for a fractured left femur.
The RN employed in a medical center in a large metropolitan area was asked to resign after consistently failing to report changes in clients status to the health care provider. The RN subsequently applied for a staff nurse position in another hospital. Which action is best for the nurse manager to take when the new employer asks for a reference?
Inform the new employer about occurrences.
The nurse receives a call from the emergency management team that a bomb exploded on a train and that 30 victims will be transported to the hospital in 10 minutes. Which of the following actions should the nurse take FIRST?
contact the nursing supervisor
Ten clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the emergency department (ED). Which client should the nurse see first?
a client with a blood pressure of 90/60 and apical pulse of 120 bpm
**vitals indicate shock here
**vitals indicate shock here
The nurse notices a patient diagnosed with major depression crying in the day room. The nurse puts her hand over the patient’s shoulder and states, “Let’s talk about it.” Which of the following ethical principles describe the nurse’s action?
The nursing team consists of two RNs, two LPN/LVNs, and two nursing assistive personnel. Which client assigned to the LPN/LVN does the LPN/LVN question?
An infant with a palpable olive-shaped mass int eh epigastrium and frequent vomiting.
The nursing team consists of two RNs, one LPN/LVN, and two nursing assistive personnel. The nurse considers the assignment appropriate if the LPN/LVN is required to complete which task?
Administer a tube feeding for the client with dysphagia.
The nurse is seeing clients in the gastrointestinal clinic. Which client should the nurse see first?
A 3-year-old infant experience projectile vomiting and irritability.
Four clients from a house fire are transferred to the emergency department (ED). Which client will the nurse see first?
A 20-year-old with full thickness burns to the face and chest area.
A nurse begins employment in a hospital using the SOAP system of documentation. The nurse understands that SOAP is an acronym for which information?
Subjective, Objective, Assessment, Plan
Four injured firefighters are transferred to the hospital. The nurse performs triage in the emergency department. Which client will the nurse assess first?
A firefighter diagnosed with carbon monoxide poisoning.
The nursing team consists of two RNs, two LPN/LVNs, and two nursing assistive personnel. The nurse considers the assignment appropriate if an LPN/LVN is required to complete which task?
Perform a sterile dressing change.
The pediatric community health nurse plans visits for the day. Which client will the nurse see first?
A 6-year-old with elevated temperature, cough, and fine crackles.
The nurse on the cardiac unit recognizes which as the primary goal of managed care?
The nurse cares for clients in a gynecological clinic. Which of the following clients should the nurse see FIRST?
A 35-year-old female who had a hysteroslapingogram and is experiencing tachycardia and has a generalized rash.
The charge nurse supervises care of clients on the medical/surgical unit. The charge nurse determines care is appropriate if which task is delegated to the nursing active personal (NAP)?
The client diagnosed with chronic obstructive pulmonary disease needs vital signs taken.
The nurse manager wants to implement a three-day workweek on the nursing schedule. The nurse manager states, “Anyone who doesn’t go along with the change will not receive vacation this this year.” The staff identifies that the nurse manager is demonstrating which type of power?
The nurse reporting suspected child abuse is legally operating under which concept?
Duty to Disclose.
The nurse care for clients in the child psychiatric clinic. Which client should the nurse see first?
A child with auditory hallucinations.
The nurse is seeing patients in the adolescent psychiatric clinic. Which of the following patients should the nurse see FIRST?
A 15-year-old who wants to be a model and only drink water and eats vegetables.
The charge nurse is having difficulty making an appropriate assignment for the nursing team. Which assessment by the supervisor will help the charge nurse make the assignment for the day shift?
“Describe the knowledge and skill level of each member of your team.”
What is the primary focus of the NCLEX-RN?
Assessment of minimum competency.
Children from a school bus accident are transferred to the hospital. The nurse triages int eh emergency department (ED). Which child should the nurse see first?
A 7-year-old with burns on 10% of the total body surface area.
After receiving the night shift’s report, the nurse plans assignments for the day. Which client should the nurse see first?
A 17-year-old who took 10 methylphenidate and has a blood pressure of 160/100.
A psychiatric nurse is presented with a group of patients in the ER. Which of the following patients requires immediate attention?
A 24-year-old male who failed medical school and says, “My pain will be over soon.”
The nurse educator wants to enhance the creative and critical thinking skills of the nurses on the medical surgical unit. Which activity is best for the nurse educator to incorporate into an inservice in order to move toward this goal?
The client is admitted with a stroke. The nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting, and feedings. The delegation is appropriate if the RN delegates the tasks of bathing and toileting to which staff member?
The nursing assistive personnel.
The nurse is dissatisfied about the standard of care on the oncology unit. The nurse discusses this with other nurses and a local news station. Afterward, the nurse is asked to resign by the nurse manager. The nurse responds to the nurse manager, “You can’t fire me because I am protected by the whistle-blower law.” Which stamen best describes why this nurse may be subjects to being fired?
The nurse may not be covered the whistle-blower law
The new charge nurse is hired to manage the pediatric unit. The charge nurse starts in a meeting, “I run my unit with a lot of control and make all the decisions.” The staff recognizes the new charge nurse is practicing which leadership style?
A series of inservice on team devleoemtn are being held for nurse managers at a teaching hospital by the staff development department. The educator has just reviewed the concepts of group process roles and identified several of them by name. One of the managers asks, “Could you please explain what exactly is meant by the gatekeeper role?” Which of the following responses by the educator is best?
“The gatekeeper ensures that everyone has an opportunity to speak.”
The medical nurse reviews charting principles with newly assigned LPNs/LVNs. Which of the following should the nurse indicate is charting that reflects subjective data?
“Patient states ‘I have had pains in my stomach for 3 days now.”
Student nurses discuss characteristics of good documentation. The student nurses identify which of the allowing adheres to the legal guideline of appropriate documentation?
A nurse documents changes to the patient’s condition
The nurse manager researches models of care delivery and decides to further explore primary nursing. The nurses manager identifies which model best describe primary nursing?
One registered nurse is responsible for the client’s total care throughout the client’s hospitalization.
The nurse enters the room of a client admitted for evaluation of a convulsive disorder. The family members present report the client just had a seizure. After determine vital signs are normal, there are no injuries, and placing the client in side-lying position, which action will the nurse take next?
Interview the family about what they observed and accurately document their response using their own words.
after receiving the night shift’s report, the nurse plan assignments for the day on the pediatric unit. Which client will the nurse see first?
A client diagnosed with hemophilia reporting join pain.
The nurse team caring for clients on the pediatric unit consist of one RN, two LPN/LVNs, and three nursing assistive personnel. Which client does the nurse assign to the nursing assistive personnel?
A child who needs help socializing with other children.
The nurse recruiter for a hospital addresses senior nursing students attending an open house in the facility. The recruiter states an advantage of working at the institution is they have recently implemented a clinical ladder system. A student asks what that means. Which is the best response by the recruiter?
“A clinical ladder allows the nurse to stay at the bestie and still progress in the profession.”
The nurse knowns that which of the following documents is backed by the force of law?
Nurse practice acts.
The nurse in the ED informs a client, ” The physician is very busy and will see you in 30 minutes.” The client demands to see the Director of Nursing. Which of the actions by the nurse is MOST appropriate?
Report the situation to the nurse’s immediate supervisor.
The nurse is seeing patient sin the psychiatric clinic. Which of the following patient should the nurse see FIRST?
A 15-year-old male brought in by police bc he threatened to jump off a bridge and has access to a gun.
The nurse manager of the psychiatric day hospital is reviewing group theory as part of the orientation of new nursing staff who are to develop and lead groups. The manner should identify which of the following group process stages as the one in which members are most likely to engage in power arguments and power struggles?
The nurse cares for clients in the psychiatric ED. Which client will the nurse see first?
a client receiving haloperidol experiencing an oculgyric crisis
The parents of an adult child have just been informed the the client will die shortly. The parents do not want the nurse to discuss the situation with the client. The nurse states, ” I will be truthful.” The nurse’s action is based on which ethical concept?
The nurse is seeing patient sin the pediatric clinic. Which of the following patients should the nurse see FIRST?
A 9-year-old who has used a weapon against his mother and caused physical harm to others.
The student nurse discusses causes of malpractice suits with the instructor. The instructor intervenes if the student includes which occurrence as an example of malpractice?
Failure to document within 30 mins after a change in the clinical condition.
The nursing team consists of an RN, two LPN/LVNs, and two nursing assistive personnel. It is most appropriate for the nurse to care for which client?
A client 24 hours after a laminectomy with spinal fusion having difficulty voiding.
Which of the following client statements about advance directives MOST concerns the nurse on the medical-surgical unit?
“My living will is all made out and secure in my safe deposit box.”
The community health maternity nurse plans visits for the day. Which client should the nurse see FIRST?
a newborn with pallor
The nurse is seeing clients in the medical-surgical unit. Which client will the nurse see first?
A client dx w/ HF who received 800mL of IV fluids in 2 hours
The nurse manager delegates a tasks to another staff member. Which of the following includes appropriate techniques to use when delegating?
The nurse manger maintains eye contact, the nurse manager states what, how, and when a task should be performed.
An RN receives the assignment for the day shift. Which client is appropriate for ht nurse to delegate to an LPN/LVN with 30 years of experience?
A client three days post requiring a dressing change.
The nurse describes the new nursing vice president’s stye of leadership. The nurse states, “The vice president lets us do what we want.”The nurse is describing which leadership style?
The nurse manager discusses substance abuse among nurses. The nurse knows which activity alerts the nurse manager to a potential problem with substance abuse among the staff?
A staff member doe snot allow another nurse to sign when narcotics are wasted.
An RN discusses delegation with a new nurse. Which of the following statements by the new nurse indicates an understanding of the meaning delegation?
Delegation occurs when an RN assigns a specific function or aspect of patient care to an LPn/LVN or UAP.
The nurse reviews the client care given by another RN to a group of psychiatric clients. The nurse knows this is which type of review?
Four clients in the ER are complaint of side effects from their medication. Which of the following clients should the nurse see first?
A client receiving clozapine and experiencing flu-like symptoms.
The RN has assessed clients on the psych unit. Which activity is appropriate for the nurse to delegate to a nursing assistive personnel on a psych unit?
Perform 30-min check on each client
In an effort toe heighten staff awareness about group process and their participation in it, the nurse manage plans an inservice focused on the roles people take in groups. Which of the following should be described as the function of the role of coordinator?
The coordinator clarifies relationships between various ideas or suggestions, thus bringing them together.
After receiving the night shift’s report, the nurse plans assgimetns for the day on the Endocrinology Unit. Which client should the nurse see first?
A 70-year old with a fasting blood glucose of 517 mg/dL.
The nursing team on the pediatric unit consists of one RN, one LPN/LVN, and two nursing assistive personnel (NAP). Which client does the nurse assign to the LPN/LVN?
the infant requiring antibiotic ointment on the circumcision site.
During the admission interview of a client admitted for cardiac surgery, the nurse inquires about the existence of advance directives, using the terms ‘living will’ and ‘durable power of attorney for health care.’ The client becomes upset and shouts, “I do not need an advance directives. I already have a will and an attorney who helps me with everything. Besides, I am not going die!” Which response by the nurse is best?
“A regular will and atoner do not cover healthcare situations, including if you cannot, even temporarily, make your wishes known.”
An RN from the psych unit is reassigned to the pediatric unit. Which client assignment is most appropriate for this nurse?
A child experiencing separation anxiety who wants to stay home with parent instead of going to school.
A day shift nurse gives change of shift report to the next nurse. The nurse knows which information is inappropriate for the nurse to include in the change of shift report?
Nurses’ opinions about clients.
The nurse informs the nurse manager that she will be taking four weeks off because she is adopting two children. The nurse manager identifies which of the following acts allows the nurse to take the time off?
Family and Medical Leave Act
A news reporter wants to take a picture of a movie star on the medical/surgical unit. Which action by the nurse is most appropriate?
Call the nurse manager.
The nurse prepares a client for discharge form the neurological unit. The client must sleep with the head of the bed elevated 30 degrees, and the client cannot afford to buy a hospital bed that can be adjusted with levers or electronic devices. The nurse learns the client’s insurance company will also not pay for the bed. What is the best action fro the nurse to take?
Instruct the client to collect or buy several pillows.
The director of nursing wants to implement all-day visitor’s passes. The nurses expressed their dissatisfaction about this potential change. The director states, “if you all agree with me, you will get a lunch pass at the hospitals expense.” The nurse identifies the director is using which type of power?
The community health nurse plans visits for the day. Which client will the nurse see first?
A 76-year old with a laryngectomy reporting a greenish-yellow discharge.
The nurse educator reviews conflict management strategies with new nurse managers. Which strategy does the educator highlight as most likely to be successful when there is conflict among staff?
Ask for suggestions for resolution from those involved in the conflict
The community health nurse plans visits for the day. Which of the following patients shoudl the nurse see FIRST?
A 13-year-old female vomiting every day for the last 3 months bc she wants to lose weight for the summer
An outside change agent consultant informs the nurse manager that most of the staff on the medical unit can be classified as “early majority” in terms of their behavioral patterns in response to change. The manager understands this to have which meaning?
The staff will not be the first to accept a change, nor will they be the last.
The nurse collapses minutes after putting on latex gloves, and the cardiac team successfully resuscitates the nurse. The nurse manager discusses that certain workers may be at greater risk for 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 nurse w/ a hx of GI upset
A nurse approaches the nurse manager to ask for a raise. After some discussion about why the nurse feels a raise is warranted, the nurse manager suggests they discuss the raise further over dinner. The nurse reverse, and the nurse manager replies, ” No dinner, no raise.” Which action does the nurse take first?
Immediately inform the nurse manager that the nurse does not want to go out to dinner
Clients from a plane crash are transferred to the hops tail. The nurse performs triage in the emergency department. Which client should the nurse see first?
A 20-year-old with burns to the chest and face area.
An RN from the maternity floor is reassigned to the emergency department. Which assignment is most appropriate for the maternity nurse?
The client at 20 weeks gestation reporting a small amount of vaginal bleeding.
An Rn has received report and assesses the clients on the unit. It is most important for the RN to assign which client to the LPN/LVN?
A client diagnosed with COPD who requires ambulation twice during the evening.
The nurse reviews 10 chart on the medical unit. The nurse identifies which of the following action is appropriate?
Failure to document that an incident report was completed.
The nurse inserts an IV into an client diagnosed with acquired immunodeficiency syndrome (AIDS). The client moves, and the used needle sticks into the nurse’s forearm. Which action best describe OSHA’s requirements for what the employer must provide in this situation?
Immediate medical evaluation and treatment
The registered nurse assigns the clients diagnosed with a myocardial infarction (MI) to another registered nurse. The client receives the wrong medication by the assigned RN. The assigning nurse knows that which statement is true?
When an RN assigns care to another RN, both accountability and responsibility are transferred.
The nursing team consists of two RNs, tow LPN/LVNs, and two nursing assistive personnel (NAP). Which client does the nurse assign to the nursing assistive personnel?
Assist an elderly client with lunch
The nurse is seeing clients in the pediatric clinic. Which of the following clients should the nurse see FIRST?
A 9-month-old infant with failure to gain weight and a blood lead level of 70 ug/dL
The nurse understands that risk management, within the context of managed care, focuses on which principle?
Prevent and minimize institutional and treatment factors that could lead to legal liability.
The nurse describes the nurse manger’s style of leadership. The nurse states, “My nurse manager involves us in making decisions about client care.” The nurse is describing which leadership style?
The nurse observes a student nurse give a presentation about incident reports. The nurse should intervene if the nursing student states that which of the following situations requires an incident report?
The physician orders dioxin (Lanoxin) to be administered at 0900. The nurse administers the mediation at 0920.
Which client assignment on a maternity unit does the nursing assistive personnel question?
Administer acetaminophen for pain to a client who has an episiotomy.
The nurse manager plans to conduct a performance appraisal. The nurse manager knows which action is most important during the interview phase?
Maintain the focus on job position requirements, standards of care, and actual employee behaviors.