"My partner hurts me. I don't want to go home." - ANS - refer the client to social services for
assistance in seeking safe housing
it is the duty of the nurse to assist the client in finding safe housing and protection from the
offending partner.
\a group of nurses on telemetry unit informs a nurse manager that there is a need to update the
cardiac monitoring system to improve arrhythmia detection. which of the following responses
should the nurse manager make? - ANS - this purchase will need to be addressed in the capital
budget plan for the unit
the capital budget plans for the expenditure of money for equipment and major purchases that
have a long life of use.
\a home health care nurse is conducting a home hazard assessment. for which of the following
findings should the nurse intervene? - ANS - the clients household lamps have 40 watt light
bulbs installed
the nurse needs to intervene for low wattage light bulbs. inadequate lighting increases the risk
for falls and presents a safety hazard for the client.
\a new nurse manager on a busy oncology unit keeps her office door closed when she is in the
office, and does not off to help resolve daily staffing issues. which of the following types of
leadership behavior is the nurse manager displaying? - ANS - laissez-faire
laissez-faire leader provides little support of guidance. the leader's activity is minimal and makes
for a less efficient staff.
\a nurse enters a client's room and discovers a small fire in a trash can. what does nurse do
first. - ANS - move the client out of the room
safety and risk reduction framework.
\a nurse enters the room of an older adult client and finds him attempting to crawl over the side
rail. which of the following actions should the nurse take? - ANS - ask an assistive personnel to
sit with the client
this client is at risk for falling. having an AP sit with the client protects him from harm.
\a nurse in a provider's office observes a newly licensed nurse taking a client's health history
while in the waiting area. which of the following actions should the nurse take? - ANS - speak to
the nurse immediately in private
violating confidentiality and federal HIPAA regulations.
\a nurse is administering medications to a client who is recovering from a stroke and has
right-sided paralysis. the nurse places the client's medication on the left side of the mouth and
, administers pills one at a time. which of the following ethical prinicples is the nurse displaying? -
ANS - nonmaleficence
\a nurse is admitting a client who has active gastrointestinal bleeding. which of the following
tasks is appropriate for the nurse to delegate to an assistive personnel (AP)? - ANS - show the
client how to use the nurse call light
should not delegate obtaining initial set of vital signs. nurse should assess client prior to
delegating tasks to determine if the client is medically stable.
AP can not listen to bowl sounds (not in scope of practice)
asking pt if they have allergies is part of admission assessment, no within ap scope of practice
\a nurse is caring for a client who asks if the client in the next room is in pain because she cries
out frequently. which of the following statements should the nurse make? - ANS - does the
crying out bother you?
\A nurse is caring for a client who has a history of severe multiple sclerosis and asks the nurse
about competing a living will. which of the following statements should the nurse make? - ANS -
i will provide you with the information you need to complete advanced directives
under the patient self-determination act, health care institutions are required to provide
educational materials advising clients of their rights to make their personal wishes known
regarding treatment.
\a nurse is caring for a pt with breast cancer and is to have a mastectomy. the client tells the
nurse she is concerned about how her partner will react to the procedure. which of the following
responses should the nurse make? - ANS - would you like me to have a member of a breast
cancer support group visit with you
nurse should serve as an advocate for this client.
\a nurse is delegating tasks to an AP for the care of a group of clients. which of the following
statements should the nurse make? - ANS - transport the client in room 203 to the radiology
department at 1000
\A nurse is participating in a continuous quality improvement program. the nurse is reviewing
medical records to determine the time of first postoperative ambulation of clients who had
abdominal surgery. in which of the following quality audits is the nurse participating? - ANS -
process
\a nurse is participating on a facility committee charged with developing and implementing new
documentation forms. the nurse should recognize which of the following factors as a potential
restraining force for implementing this change? - ANS - staff resistance to learn new forms for
documentation
\a nurse is planning care for a client following a coronary arterial bypass graft procedure. the
nurse places a referral for a case manager to visit with the client. which of the following
information should the nurse provide the client about the role of case manager. - ANS - the case
manager will coordinate and plan your care while you recover from your surgery
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