ATI leadership practice A
A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?
-Inform the client of ...
ATI leadership practice A
A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that
he will not have the surgery. Which of the following actions should the nurse take?
-Inform the client of the consequences of decreased cerebral circulation
-Initiate a mental health consultation to determine why the client refuses the surgery
-Discuss the client's concerns about having the surgery
-Provide the client with information on additional treatment options - ANSWER Discuss the client's concerns about having the surgery
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a LTC facility. Which of the following actions should the
team take to evaluate the effectiveness of the plan?
-Compare data from clients' records regarding skin integrity with established criteria
-Measure staff attendance at an educational program on managing pressure injuries
-Interview clients regarding their satisfaction with their care
-Monitor use of supplies used to prevent pressure injuries - ANSWER Compare data from clients' regarding skin integrity with established criteria A nurse asks a newly hired assistive personnel to remove a client's indwelling catheter. Which of the following actions should the nurse take to ensure they are qualified to perform this task?
-Show them how to remove an indwelling catheter
-Review their skill competency checklist
-Ask them if they know how to remove an indwelling catheter
-Pair the newly hired AP with an experienced AP - ANSWER Review their skill competency checklist
A nurse is caring for 4 clients. Which of the following assessment findings is the priority?
-A client who has facial drooping following a stroke 8hrs ago
-A client who has a femur fracture and reports feeling short of breath
-A client who had an appendectomy 12hr ago and reports pain as 5 -A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing - ANSWER A client who has a femur fracture and reports feeling short of breath
A home health nurse is planning her daily visits and receives labs for 4 clients. The
nurse should first visit the client who has which of the following labs?
-Digoxin 1.0 ng/mL
-WBC 6,000
-Platelets 100,000
-Serum potassium 4.0 - ANSWER Digoxin 1.0 A nurse is assigning care for 4 clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
-Instruct a client how to take their BP
-Administer subcutaneous medications to a client
-Determine a client's I/O
-Provide a status update to a client's family member - ANSWER Determine a client's I/O
A client who has back pain presents to an ED and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?
-It sounds like nonpharmacological interventions would be best for this client
-Let's withhold the oxycodone until we can consult with the provider
-Contact mental health services to arrange for a consultation
-Clients are the experts on their own pain - ANSWER Clients are the experts on their own pain
A nurse is observing a newly licensed nurse perform a sterile dressing change on a
client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?
-Open the top flap of the sterile package towards the body
-Maintain a 0.5in border around the edges of the sterile field
-Pick up the first sterile glove by grasping the folded cuff edge
-Remove soiled dressings using sterile gloves - ANSWER Pick up the first sterile glove by grasping the folded cuff edge
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