3 7. A charge nurse is evaluating the implementation of infe

3 7. A charge nurse is evaluating the implementation of infection…  37. A charge nurse is evaluating the implementation of infection control measures by unit nurses when caring for clients who have c.difficile. The charge nurse should intervene for which of the following actions by the unit nurse? a. Places the client in contact precautions b. Cleans contaminated equipment with bleach-based solution c. Uses alcohol-based hand sanitizer after removing gloves d. Wears goggles when emptying the bedpan of liquid stool 40. A charge nurse overhears a provider and a nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first? a. Discuss the need for client confidentiality at the next staff meeting b. Remind them that client information is confidential c. Comp an incident report about the situation d. Report the incident to the nurse supervisor41. A nurse is delegating tasks to assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? a. Determine whether an oxygen flow meter is accurately set at 2L/min via nasal cannula b. Tag a malfunctioning piece of equipment as broken c. Check on a client whose telemetry monitor is continuously beeping d. Instruct a client about the use of an incentive spirometer 42. During a staff meeting, a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? a. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark b. Include documentation of client education as part of unit nurses’ annual performance evaluation c. Train LPNs to reinforce teaching with clients using a standardized teaching plan d. Determine factors that interfere with the documentation of client education  45. A client who is unconscious and has extensive internal injuries arrives via ambulance to the ED. The staff cannot reach the client’s family. Which of the following permits the staff to proceed with the emergency surgery? a. Implied consent b. Good Samaritan Act c. Living will d. Nonmaleficence  46. A nurse is teaching a newly licensed nurse about the purpose of interdisciplinary conferences. The nurse should identify that which of the following clients needs an interdisciplinary conference? a. A client who had a recent stroke and is showing manifestations of depression b. A client whose provider is unhappy with the nursing care c. A client whose partner requests that the client be moved to a private room d. A client whose MRI results have not been made available after 2 days  47. A nurse is caring doe a client who is scheduled for a hysterectomy and has signed the informed consent form. The client tells the nurse she is unsure about having the procedure. Which of the following responses should the nurse make? a. You should not have signed the consent form if you have reservations about the surgery b. Let me provide you with resources you can read about the surgery c. If you have any concerns about the procedure, the surgery can be canceled d. I will contact the provider and request medication to help you relax  48. A charge nurse in the ED is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse? a. Administer IV nitroglycerin to a client who is experiencing chest pain b. Set up a trauma room for an incoming client who was in a motor vehicle person crash c. Com  a SAD PERSONS assessment scale for a client who has attempted suicided. Perform a urinary catheterization for a client who has experienced a cerebrovascular accident  49. A nurse in the medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? a. Instructing a client on self-administration of tap water enema b. Suctioning a client’s long-term tracheostomy c. Using a pain rating scale to monitor a client’s pain level d. Performing a dressing change on a client’s peripherally inserted central catheter  50. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? a. A nurse on the previous shift wrote an incident report about a medication error b. Transport assistance is unavailable to take a client to occupational therapy c. The emergency department nurse is waiting to give report on a new admission d. Two staff members have called to say the will be absent  51. A nurse manager is reviewing the nurse code of ethics with the staff nurses. Which of the following statements by a staff nurse indicate understanding of the teaching? SATA a. “I have the assistive personnel double-check packed RBCs when other nurses are busy” b. “I will attend continuing education classes for professional growth” c. “The family of a newly admitted client recently treated me to lunch in the hospital cafeteria” d. “I administer pain medication to my clients even if they have a history of narcotic addiction” e. “I can delegate the removal of an IV catheter to an LPN on the unit”52. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care? a. Is the client’s family present so the AP can show them how to turn the client? b. Has the AP checked the client’s pain level prior to turning her? c. Does the AP have time to change the client’s central IV line dressing after turning her? d. Has data been collected about specific client needs related to turning?  53. A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? a. Obtain a prescription for a sedative for the client b. Raise all four side rails on the client’s bed c. Remove the clock and calendar from the client’s room d. Provide distractions for the client during the day  54. A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? a. A client who is at risk for pressure ulcers and has an albumin level of 4.2g/dL b. A client who has type 1 diabetes and uses an insulin pump c. A client who has orthostatic hypotension and is receiving IV fluids d. A client who is receiving heparin and has an aPTT of 34 seconds  55. A nurse is caring for a client who is scheduled for coronary artery bypass surgery and does not wish to have any blood transfusions. The nurse should recognize that administering blood to this client is a violation of which of the following ethical principles? a. Veracity b. Fidelity c. Justice d. Autonomy 56. A nurse on surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? a. The steps to follow when providing would care b. The belief that the client has a difficult relationship with his son c. The client preferred time for bathing d. The time the client received his last dose of pain medication  57. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology? a. Impaired voluntary cough b. Unilateral ptosis c. Altered level of consciousness d. Diminished hand-to-mouth coordination 58. A nurse in the emergency department is assessing a preschool-age child who has bruises on both arms and a spiral fracture of the left ulna. The child’s parents tells the nurse that the child tripped over some toys and fell down. Which of the following actions should the nurse take? a. Report the child’s injuries to child protective services b. Take pictures of the child’s injuries once the parent leaves the room c. Have a facility security officer interview the parent d. com an incident report concerning the child’s injuries 60. A charge nurse is teaching a group of nurses about the purpose of a living will. Which of the following information about living wills should the charge nurse include in the teaching? a. Addresses resuscitation measures b. Provides protection against malpractice c. Documents that the client gave informed consent d. Designates a health care surrogate to make health care decisions 61. A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make? a. “I cannot provide this information to you without your mother’s consent” b. “You will have to speak directly to your mother about her treatment” c. “I will ask your mother’s primary care provider to speak with you” d. “What would you like to know about your mother’s treatment”  62. A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnosis a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse take? a. Ask the adult neighbor to sign the consent form b. Attempt to notify the client’s guardian to obtain consent c. Witness the client signing the consent form d. Obtain consent from the hospital administrator  63. A nurse is participating in an interdisciplinary conference for a client who has heart failure, report limited resources and lives alone. Which of the following action is the nurse’s responsibility? a. Order durable medical equipment for the client’s home b. Perform a dietary assessment c. Help the client obtain financial assistance d. Coordinate the team and the plan of care 65. A nurse is preparing to transfer a client from the emergency department to a medicalsurgical unit using the SBAR communication tool. Which of the following should the nurse include in the background portion of the report? a. The client’s name b. The client’s code status c. A prescribed consultation d. The client’s vital signs 68. A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure? a. Lists names of witnesses to the fall in nurses’ notes b. Documents in the client’s record that an incident report was filed c. Sends the incident reports to the ethics committee d. Includes the client’s account of the fall in the incident report 70. A nurse has just completed assessment charting on the electronic record for an assigned client. Assistive personnel (AP) who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take? a. Allow the AP to document the vital signs prior to logging out b. Log out so the AP can log in to document the vital signs c. Offer to chart the vital signs for the AP d. Recommend the AP come back later when the record is available.Health Science Science Nursing NUR 233

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