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Which behavior indicates that an 18-month-old infant is developing a nonadaptive reaction to hospitalization?
A preschool child has a history of an appendectomy and is scheduled for an open reduction and internal fixation of the femur. What would be appropriate for preoperative teaching?
A nurse manager has been notified to obtain a bed for a client. Of the following clients, which one would the nurse anticipate being able to discharge?
Which of the following clients would the emergency room (ER) nurse see first?
After morning report, the nurse prioritizes care of the following assigned clients. Which client would the nurse see first?
During morning report, a staff nurse organizes her client load based on the clients’ levels of acuity. Which of the following clients would the nurse see first?
While having lunch at a table with other nursing staff, a nurse asks a nurse from another unit about a friend’s husband, wanting to know how he is progressing. The nurse from the unit should
A staff nurse is beginning the evening shift. The day nurse has advised her that the suction equipment in the room of a client who has had surgery is not working properly. What is a priority nursing action?
The nurse prioritizes the morning schedule to assess which of the following clients first?
The nurse has received a report on assigned clients. In organizing the activities of the day and planning the care of the clients, what approach would be the most effective?
What is an important consideration for the nurse when delegating an assignment?
A 6-year-old client has just received his first vaccination for hepatitis B. Which action by the parent would demonstrate understanding of immunizations for Hepatitis B?
The nurse is working with a nursing assistant (unlicensed assistive personnel) to provide care to a group of assigned clients. The nurse has worked with the nursing assistant and knows she is competent. What activity can the nurse delegate to the nursing assistant?
An RN from a postpartum unit has been reassigned to a cardiac unit because of staffing issues. The nurse is very uncomfortable and does not feel competent to deliver care on this unit. What is the best nursing action she can take?
A nursing supervisor would be most concerned about which statement made by a staff nurse after the completion of an incident report?
The Joint Commission’s (TJC) National Patient Safety Goals clearly state that healthcare facilities must implement safe approaches and procedures for client safety. Which practice has been instituted as a result of these goals established by TJC?
Which client should the nurse see first after receiving the shift report?
The nurse is planning assignments. Which task can be safely delegated to a nursing assistant?
The nurse received a report on the assigned clients for the shift. Which client should the nurse see first?
The nurse is planning assignments for the care of a group of clients. Which client would be a good assignment for an LPN/LVN?
The nurse overhears two unlicensed assistive personnel (UAP) talking. Which statement requires further investigation by the nurse?
A nurse expresses concern during report about the number of clients that have been assigned to her. She discusses her concerns with the nursing supervisor about the unsafe staffing ratio. What would be the nurse’s next action?
The nurse is concerned about cardiovascular complications caused by immobilization of a client with cardiac disease who has been on bed rest for 1 day after a colectomy. What nursing intervention can be implemented to help prevent complications?
A nurse manager notes that there is tension and arguing among the staff how the holiday work schedule. What should the nurse manager do?
The nurse notices a nurse’s aide placing an uneaten food tray on the cart where other food trays are being passed out to clients. What is the priority nursing action?
How would the nurse case manager determine the quality of care provided by a home healthcare aide?
The nurse is caring for a client who was admitted several hours ago after a motor vehicle accident. He has a broken leg and severe lacerations. The doctor’s order is for morphine sulfate, 10 mg subcutaneously (subQ), now and again in 4 hours. The second dose of pain mediation was administered 5 hours ago, and the client is now beginning to complain of severe pain. The vital signs are BP of 150/88 mm Hg, pulse of 110 beats/min, and respiration of 30 breaths/min. Temperature is 100°F (37.8°C). The nurse has attempted to notify the physician but is unable to contact him. Because the vital signs are stable and the client is in severe pain, the nurse administers the third dose of morphine, and the client’s pain is relieved. What is the nurse’s liability in this situation?
The RN assigns a nursing assistant to obtain vital signs on a client who is 1 day postoperative for a right-side mastectomy. The nurse specifically tells the nursing assistant to take the BP on the client’s left arm. The nursing assistant acknowledges the assignment. Two hours later, the RN discovers the BP cuff on the right arm of the mastectomy client. What statement best describes the liability in this situation?
A nurse is taking care of a client who is a friend and is also well known in the community. A neighbor calls the nurse at home to ask about the status of the mutual friend. The nurse tells her friend that she cannot discuss the friend’s health status with her. What resource describes the nurse’s legal responsibilities?
A client has been involved in an accident, does not speak English, is hemorrhaging, and requires immediate surgery. No one is with him. What is the best way for the nurse to handle this situation?
The nurse prepares a narcotic pain medication and gets distracted before administering the medication. Later the medication is administered to the wrong person. What type of law addresses this problem?
The nurse is caring for a client who has a do not resuscitate (DNR) current, written order on the chart. What is the best interpretation by the nurse of this order?
A nurse who lives and practices in a compact licensure state is moving to another state that also has compact licensure. What should the nurse do to legally practice in this other state?
The nurse is assessing a client with an irregular heartbeat. What would be the most effective way to determine the client’s pulse rate?
A nurse has a compact multistate license and has accepted a temporary assignment in another compact state. The nurse’s employer or staffing agency told the nurse that she needs to apply for that particular state’s license. The nurse questions the employing agency about this policy based on which of the following?
The nurse is preparing to send a client to the radiation department for his scheduled radiation therapy. What action will the nurse take to determine the correct identification of the client?
What is a key component of a quality improvement program?
A client has been identified as a fall risk. There is a prescription activity order to have the client ambulate with assistance. Often, the client does not wait for assistance to walk to the bathroom. What action would help protect the client from harm and reduce the nurse’s legal liability?
How does the nurse handle a situation when she is caring for a parent of a close friend and the close friend asks the nurse for an update on her father’s condition on a social networking website?
Which of the following is a Centers for Disease Control and Prevention (CDC) Category A biologic agent?
What is the most likely source of exposure in a biologic weapon attack?
Which of the following is an example of a Level I disaster?
Which of the following is an example of a Level II disaster?
Which of the following events is an example of a Level III disaster?
The nurse is performing a dressing change on a client with an abdominal wound with a Penrose drain. What essential information will the nurse document?
Which of the following conditions satisfies a “green” triage tag in an emergency triage scenario?
A primary nursing intervention to prevent postoperative respiratory complications would include which preoperative teaching?
While preparing a client for a scheduled surgery, the nurse notices the client wringing her hands, moving around in her seat, and breathing rapidly. The nurse does a physical assessment and finds a rapid pulse of 128 beats/min with moist, clammy skin. The client states, “I’m so nervous.” Which prn medication should the nurse consider administering to the client?
The nurse is assessing a client who is recovering from a surgery that was performed using a local anesthetic. The client’s speech has become very slurred. What would be the nurse’s priority action?
The nurse observes a nursing assistant using antiseptic hand rub and rubbing the hands vigorously after leaving the room of a client diagnosed with Clostridium difficile. Which action is most appropriate by the nurse?