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Leadership Prep
| Question | Answer |
|---|---|
| cough, headache,aches and pains. a temperature of 102.5° F (39.2° C) and redness on the arms, legs, and upper chest. She also notes that the client takes eight different medications each day. What nursing diagnosis is the priority for this client? | Impaired Skin Integrity |
| (see full question) A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for: | fluid replacement. |
| After completing the nursing assessment for a client and family entering the palliative care program, the nurse should develop a teaching plan that includes an understanding of which of the following outcomes? Select all that apply | • Achievement of a dignified and respectful death. • Improvement in the client's quality of life. • Provision of comfort during the dying process. • Provision of support for client and family |
| employee's blood pressure elevated two occasions 1 month apart employee is about 25 lb overweight and has smoked a pack of cigarettes dail The client's physician prescribes atenolol hypertension. The nurse should instruct the client to: | Avoid sudden discontinuation of the drug. |
| The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 lb in 1 day. Based on these data, which of the following nursing diagnoses is appropriate? | Excess fluid volume related to the kidney's inability to maintain fluid balance. |
| A 15-year-old girl with a urinary tract infection is admitted to the facility. She tells the nurse she hopes she's pregnant. How should the nurse respond? | Tell me what being pregnant would mean to you." |
| The nurse is caring for a client from Southeast Asia who has HIV-AIDS. The client does not speak or comprehend the English language. What should the nurse do to provide culturally-appropriate care? | Utilize language-appropriate interpreters. |
| A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. What is appropriate for the nurse to say to the client? | "Taking several medications can be difficult. Tell me about the difficulties you're having." |
| A registered nurse should assign a nursing assistant to care for a client with inflammatory bowel disease who: | requires assistance with ambulation. |
| A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. the client asks why he should see anyone other than this nurse. What is the nurse's best response? | We're very concerned about your foot and we want to provide the best possible care for you." |
| A nurse is assigning the care of a client admitted with appendicitis. She should assign this client's care to a: | registered nurse. |
| Which of the following is an appropriate expected outcome for a client recovering from a total laryngectomy? The client will | Communicate feelings about body image changes. |
| A 15-year-old girl is sent to the school nurse with complaints of dizziness and nausea. While assessing the girl, who denies any health problems, the nurse smells alcohol on her breath. Which of the following responses by the nurse is appropriate? | Tell me everything that you have had to eat and drink yesterday and today." |
| 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive: | Hydromorphone (Dilaudid) IV. |
| Which client statement indicates that the client has coped effectively with a relationship problem? | We are really listening to each other about our different view on issues." |
| The nurse has paged the interpreter several times. Which of the following should the nurse do ? | Reschedule the infant's appointment for later in the week. |
| Which of the following is true of an ethics consultation? Select all that apply. | Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. • Ethics consultations may prevent poor outcomes in cases involving ethical problems. • The recommendations of ethics consultants are advisory only. |
| attempting suicide by ingesting acetaminophen (Tylenol). The nurse should incorporate which interventions into the care plan for this girl? Select all that apply | • Ask the girl's parents if they keep firearms in their home. • Ask the girl if she's currently having suicidal thoughts. • Assist the girl with bathing and grooming as needed. • Inspect the girl's mouth after giving oral medications |
| "Read-back" procedures should be performed in which of the following situations? Select all that apply | When a medication order or critical lab result is received verbally or over the telephone. • When any verbal or phone order is received. |
| discharges during a disaster event so clients involved in the disaster can be admitted promptly. After quickly reviewing the client census, the nurse identifies five postoperative clients who may be ready for discharge. What should the nurse do next? | Assess each client, call the physician, and ask for discharge orders if appropriate. |
| The nurse-manager on the oncology unit wants to address the issue of correct documentation of the effectiveness of analgesia medication within 30 minutes after administration. What should the nurse-manager do ? | Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts. |
| A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should: | obtain a physician's order to restrain the client. |
| A client has anemia, tachycardia, hypotension, and shortness of breath. The physician has ordered 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if? Select all that apply. | I.V. access with the appropriate tubing and ns priming solution signed informed consent for transfusion therapy blood typing and cross-matching documented in medical record? vs taken and documented in• the client has an identification bracelet |
| A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood? | Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. |
| nurse-manager reviews the month's risk-management data, notices incident reports completed b/C 6 p.m. medications administered late. Dinner served between 5:30 p.m. and 6 p.m. Staff dinner breaks between 5 p.m.- 6:30. Which is the most appropriate action | Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m. |
| The physician tells the nurse that the current order for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should | Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered. |
| A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? | Administering ordered analgesics and monitoring their effects |
| A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? | The incident report will provide a basis for promoting quality care and risk management. |
| When evaluating a client's preoperative cognitive-perceptual pattern, which of the following questions should the nurse ask the client? | Do you wear glasses?" |
| The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old.Which of the following nursing interventions would be appropriate? Select all that apply | Monitor the client's level of anger and potential aggression. • Ask the client if he would like to attend a support group. • Help the client express anger safely. • Assist the client in processing his feelings about the sexual abuse |
| 1 RN, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (NCDS) should be implemented for the best possible client care during this staffing crisis | Functional nursing |
| The nurse ascertains that there is a discrepancy in the records of use of a controlled substance for a client who is taking large doses of narcotic pain medication. The nurse should do which of the following ? | Notify the nursing supervisor of the clinical unit. |
| The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should | allow adequate time for the nursing assistant to complete the task, then follow-up with her |
| Before their release, the mother tells the nurse, "I've been living in my car for the past 2 weeks." Which of the following should the nurse do ? | Contact the hospital's social worker |
| When performing an assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis? | Impaired physical mobility |
| A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about a breast prosthesis and wigs. After answering the questions directly, the nurse should also | Provide a list of resources, including the local breast cancer support group. |
| The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients ? | A mother who had a spontaneous vaginal delivery (SVD) client and received methylergonovine maleate (Methergine) 1 hour ago for increased bleeding |
| An adolescent with well-controlled type 1 diabetes has assumed complete management of his disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct him to adjust his therapeutic regimen by: | eating a snack before each gymnastics practice. |
| The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply | • A client who underwent inguinal hernia repair surgery 3 hours ago. • A client who is experiencing an exacerbation of his ulcerative colitis |
| The nurse is planning care for 4 mothers and their newborns. After reviewing the clients' charts, the nurse should make rounds on which of the following clients ? | A 35-year-old G4 P4 with an uncomplicated vaginal delivery 4 hours ago. The nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm. |
| client delivers a neonate at 24 weeks' gestation. neonate's condition deteriorates, and death appears likely within the next few minutes. The parents are Roman Catholic,Which of the following actions would be appropriate? | Baptize the neonate, regardless of the nurse's own religious beliefs |
| The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the physician? | The child reports having a previous surgery for a ruptured appendix |
| tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective | 5 percent of the clients required hospitalization in the last 90 days. |
Created by:
Kryszakstephanie