Leadership & Management Management Concepts

The nurse on the neurotrauma unit receives report on 4 clients.
Which client should the nurse

assess first?
A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt
force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain
can lead to decreased cerebral perfusion and herniation (mid-line shift). Assessing for signs of
increased intracranial pressure, including change in level of consciousness, Cushing triad
(hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and
vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be
necessary.
(Option 1) Manifestations of neurogenic shock include hypotension and bradycardia. Although
the client has bradycardia and requires monitoring, the client is normotensive and has normal
skin color and temperature, which indicate adequate perfusion.
(Option 2) Headache, transient change in level of consciousness, and inability to remember the
injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma
Scale score of 15 (range: 3-15) indicates complete orientation.
(Option 4) Central diabetes insipidus results from head trauma. Damage to the hypothalamus or
pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum
osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200
mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected
manifestations.
Educational objective:
A subdural hematoma is caused by bleeding into the subdural space outside the brain. Surgical
evacuation of the hematoma may be necessary to relieve the pressure on the brain, as increased
intracranial pressure can lead to decreased cerebral perfusion, herniation (mid-line shift), and
death.
Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural
practices of the clients on their assigned unit. Which leadership strategy is best for the nurse
manager to implement to assist the graduate nurses in developing cultural competency?
The transformational nurse manager provides a supportive culture in which learning is valued
and best practices are implemented to ensure the appropriate skill level and experience of each
staff member. A workshop would provide the graduate nurses with an opportunity to learn and
ask questions about the cultures represented on their unit. It would also help develop cultural
awareness and sensitivity, leading to respect for the diverse cultures represented on the unit.
(Option 1) Cultural diversity is present in every clinical unit; therefore, it is not feasible to
assign the graduate nurses to a unit without cultural diversity.
(Option 3) To provide culturally competent care, the graduate nurses must know about the
various cultures represented on their unit. Culturally competent care is first attained through
education. Afterward, the graduate nurses are ready to implement best practices in the care of
clients from diverse cultures.
(Option 4) Although researching various cultures would assist the graduate nurses in learning,
the new graduates are novices and have not fully developed cultural competency; therefore, they
are not the best individuals to provide an in-service on this topic.
Nurse managers must ensure that the nursing staff can provide quality care to clients on the unit
through development of the necessary skills, including cultural competency. Nurse managers
can find mentoring and continuing education programs and Internet resources useful in
developing the cultural competencies of staff nurses.
The charge nurse is reviewing clients' medical records on the cardiovascular care unit. Which
client care outcomes are appropriate? Select all that apply.
Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing

embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg,
petechiae, purpura) (Option 1).
Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque
from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension,
tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental
status) (Option 2).
Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and
avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac
arrhythmia) (Option 4).
A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of
clients with peripheral arterial disease. After the procedure, the client should be able to ambulate
without evidence of extremity ischemia (eg, leg pain) (Option 5).
(Option 3) A percutaneous coronary intervention (PCI) is a procedure used to restore
coronary perfusion to prevent or treat ischemia or infarction. Clients having undergone a PCI
would be expected to have no chest pain at rest. Chest pain at rest indicates myocardial
ischemia.
Clients receiving heparin should remain free from heparin-induced thrombocytopenia. After
carotid endarterectomy, clients should remain free from hemorrhage and neurological
impairment. Those receiving loop diuretics should maintain electrolytes within normal limits.
After a femoral-popliteal angioplasty, clients should be able to ambulate without leg pain. They
should have no chest pain at rest after a percutaneous coronary intervention.
The nurse is discharging a client with emphysema who is on continuous oxygen. The case
manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What
action should the nurse take?
The nurse (with the case manager) needs to assure that the client has the essential
equipment/supplies for a smooth discharge into the home environment. The safest option is to
delay discharge until that can be accomplished.
(Option 1) It is not appropriate to ask the client to go without the oxygen as it would mean not
following the client's prescription. The client could arrive home and then require oxygen due to
additional exertion.
(Option 3) The issue is not the client's need or the prescription but the logistics of
implementation. There is no need to involve the HCP as the solution is within the nurse's
abilities and control.
(Option 4) If the nurse sends the hospital oxygen tank home with the client, the question of how
it will be returned remains. It is safer and more reasonable to delay the discharge.
A client should not be allowed to leave until essential home supplies and equipment have been
made available for a safe discharge.
The health care provider (HCP) explains the risks and benefits of a procedure to the client
through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on
the consent. The interpreter and client now have a lengthy discussion in the foreign language.
The nurse should take which action at this time?
An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The
role does not include personally editorializing or embellishing with advice beyond what the
health care provider (HCP) said. It is important to find out if there was any discussion related to
the procedure or if the follow-up conversation was about other topics (eg, social). The nurse
needs to obtain feedback to be certain that the client understands about the procedure and had no
additional questions that the interpreter personally answered. The nurse can ask the client
additional questions using this interpreter or use a different interpreter/a language line.
After the nurse is satisfied that no additional information was provided and the client understands
what the client is signing, the nurse (as the hospital employee) should then witness the signature.
The nurse should indicate that an interpreter was used in the process.
(Option 2) Gestures/pantomime may be adequate for basic actions, such as obtaining a blood
pressure. In this case, there is specific information that must be clear and should be
communicated with interpretation. Federal law requires accommodations for people with limited
English proficiency. The Joint Commission indicates that clients' rights include translation.
(Option 3) Clarifying the content of the conversation is the priority. The nurse (as an employee
of the hospital) should be the witness whenever the signature is obtained. However, the name
and the contact information of the interpreter should be documented.
(Option 4) The consent should not be signed until it is clearly established that no additional
information/advice was given by or asked of the interpreter after the HCP left.
An interpreter should only provide literal translation of the words spoken by the HCP, not adding
any personal advice/information. The nurse should clarify if there is any question about the
accuracy or content of the translation and ensure the client's concerns have been addressed prior
to obtaining the signature on the consent.
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the
documentation of clients' capillary glucose results rather than performing the test. What is
the best action by the charge nurse to handle this situation?
The best initial result is to assess and validate the charge nurse's perception. Doing the test and
comparing results randomly/intermittently will give data to prove/disprove this concern.
(Option 1) It could cause concern to involve a client when there may be an issue about
inadequate provider care. The nurse should handle it independently.
(Option 2) It is good to reinforce policies in general announcements to the entire staff,
especially if wide-spread compliance is a concern. However, there is only one person that is
suspected of not adhering in this case. Speaking out is often a general step taken, but the
intended individuals usually don't hear the information. In addition, this is information that the
staff has known/heard before.
(Option 3) The normal discipline process is a verbal warning, a written warning, suspension,
and termination. To initiate the process, there has to be evidence of wrong doing. However, it is
only a suspicion at this point.
When deliberate inaccurate documentation is suspected, gather evidence before confronting the
staff member. One way of doing this is by checking the data personally and comparing it to
what has been documented.
Interdisciplinary client care rounds and hand-off communication are examples of strategies used
to improve communication in health care settings. What is the most important outcome of
effective communication among care givers?
Miscommunication between health care providers may cause serious medical errors when clients
are handed off or transferred. Medical errors can be effectively reduced by employing strategies
(eg, Situation, Background, Assessment, and Recommendation [SBAR] reporting
technique, nurse-to-nurse change of shift reports, multi-professional bedside rounds) to improve
communication and collaboration. Nurses should be as proficient in their communication skills
as they are in their clinical skills.
(Options 1, 2, and 3) Improved communication may aid in assessing a client's educational
needs and meeting less obvious needs; it can also contribute to a shorter length of stay.
However, these are not the most important outcomes.
Effective communication among caregivers is necessary to deliver safe client care and reduce the
number of medical errors.
Which components are used in determining the standards of professional nursing
practice? Select all that apply.
Standards of nursing practice and care are universal criteria that are used when determining
if appropriate, professional care has been delivered. The definition of this minimum acceptable
level of care reflects what reasonable, prudent, and careful nurses would do in specific
circumstances. The state or province/territory boards of nursing help to regulate these
standards.
Sources used to define standard of care include statements from professional organizations,
agency policies and procedures, textbooks, current literature, expert consensus, the Nurse
Practice Act, and statutes from regulatory organizations (Options 2, 3, and 4).
(Option 1) The standard of care includes objective criteria and does not consider intention.
Guidelines are used in determining if duties were performed in an appropriate manner. A nurse
can have good intentions but still fail to meet the standards of professional nursing practice.
(Option 5) Standard of care is determined by objective, third-party authoritative/reasonably
reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of
the event in question, can testify about their interpretation of usual custom and practice as it
relates to the incident. However, an individual's typical actions are not authoritative in
determining the universal standard of nursing care and cannot replace the use of objective,
authoritative, and predetermined standards of care.
The standards of professional nursing practice and care are defined by what reasonable, prudent
nurses would do in specific circumstances. These are based on objective, third-party
authoritative sources, including literature, laws (Nurse Practice Act), and professional
organizations.
The charge nurse on the medical surgical unit must assign a room for an immediate post-
operative nephrectomy client. Which room assignment is the best option for this client?
The best option is room 4 with the client who has severe epistaxis and decreased platelet count
(normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-
operative client at increased risk for infection.
(Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk
for infection:
 Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have
infectious complications due to increased susceptibility to infection resulting from an
altered immune response and decreased leukocyte function due to hyperglycemia. In
addition, hemodialysis increases the risk for infection due to invasive lines and catheters.
 Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-
1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can
also indicate progression of asymptomatic early infections to more advanced
symptomatic infections.
 Room 3: The client with cellulitis and an increased white blood cell count
(>11,000/mm3 [11.0 x 109/L]) has an infection.
An immediate post-operative client should not be assigned a bed in a room with a client who is
contagious or potentially infected as this poses an increased risk for infection.
There has been a community disaster with multiple victims. Stable clients must be released to
make room for the victims. Which clients would the nurse recommend as stable for
discharge? Select all that apply.
The best indication of moving air in a client with asthma is peak flow. The results are
categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal
best and caution), and red (<50% of personal best - a medical alert). This client is currently in
good control. Other findings to note include effortless breathing, no cough or wheeze, and
sleeping well all night (Option 3).
Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine
receptors. This results in weakness in skeletal muscles, especially in the bulbar region
that involves eye movement, swallowing/speaking, and breathing. Such clients become more
exhausted as the day progresses. The client can be discharged home as ptosis is an expected
finding (Option 5).
(Option 1) Normal Glasgow Coma Scale is 15; a score of 12 indicates impairment requiring
further care.
(Option 2) The varices oozing blood are at risk for rupture and/or increasing ammonia (from
the digestion of protein in the blood). This client needs treatment.
(Option 4) Normal platelet count is 150,000-400,000/mm3 (150-400 × 109/L). A potential
complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical
thrombosis (eg, stroke, arterial clots) and, rarely, bleeding.
Clients with an acute head injury and a Glasgow Coma Scale of 12, thrombocytopenia while on
heparin, or oozing varices in cirrhosis are not stable for discharge.
Ptosis
Glasgow Coma Scale
4 - Spontaneous (open with blinking at baseline)
3 - To speech
(E)ye opening
2 - To pain only
(Maximum = 4)
1 - None
(C - Not assessable [eg, trauma, edema])
5 - Oriented
4 - Confused (converses but confused, disoriented)
3 - Inappropriate (inappropriate words)

(V)erbal response
(Maximum = 5)
2 - Incomprehensible (sounds, no words)
1 - None
(T - Not assessable [intubated])

6 - Obeys commands for movement
5 - Localizes to pain
4 - Withdraws from pain

(M)otor response
(Maximum = 6)
3 - Flexion in response to pain (decorticate posturing)
2 - Extension in response to pain (decerebrate posturing)
1 - None
 Use best response for each category (range = 3-15).

 Coma: Does not open eyes, does not follow commands, and does not utter
understandable words; Glasgow Coma Score (GCS) 3-8.
 Head injury classification: Mild, GCS 13-15; moderate, GCS 9-12; severe, GCS ≤8.
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to
the medical unit. There are 4 semiprivate room beds available. Which room assignment does
the charge nurse choose as the best option for this client?
The best option is room 4 as the client with the upper gastrointestinal bleed does not put the
immunocompromised client with AIDS at increased risk for infection.
(Options 1, 2, and 3) These room options put the client with AIDS at increased risk for
infection because:
 Room 1 – C difficile is a highly contagious bacterial infection transmitted through stool
and requires contact precautions
 Room 2 – fever of unknown origin is often a symptom of an undiagnosed viral or
bacterial infection
 Room 3 – pneumonia is an infectious respiratory disease
An immunocompromised client should not be assigned to a room with a client who is contagious
or potentially infected as there is an increased risk for infection.
A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric
unit. Which client could share a room with this child?
Leukemia is characterized by unrestricted proliferation of abnormal white blood cells

(lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the
most common form of childhood cancer. Infection is a major concern due to neutropenia. In
addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a
result of decreased platelet production.
It would be appropriate for this client with leukemia to share a room with a client with minimal
change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and
poses no risk to a client with leukemia.
(Option 1) Appendicitis is a result of viral or infectious processes and can lead to rupture of the
appendix. A client recovering from a ruptured appendix poses a threat of infection to the child
who has leukemia.
(Option 2) A client with cystic fibrosis has pulmonary complications due to thick mucus that
traps bacteria. The tracheobronchial tree is colonized with bacteria and respiratory infections are
a lifelong problem. This client poses a threat of infection to the child with leukemia.
(Option 4) Rheumatic fever occurs following pharyngitis caused by group A β-
hemolytic Streptococcus. A client with this condition poses a threat of infection to the child with
leukemia.
Leukemia is a cancer of the blood and organs involved in hematologic function. Due to
myelosuppression, clients are at risk for problems related to infection, anemia, and bleeding.
The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures
that have tested positive for bacteria. Which action by the nurse is appropriate at this time?
Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements)

require immediate intervention for client safety. The nurse receiving a critical laboratory result
should notify the health care provider (HCP) as soon as possible. Hospital organizations have
individual policies regarding the time frame for notification of the HCP and HCP response,
usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications
(eg, septic shock) (Option 1).
(Option 2) The critical laboratory result should be documented in the client's medical record,
but only after immediate communication with the HCP.
(Option 3) The nurse must make direct contact, either via telephone or in person, when
reporting a critical result. A telephone message may not be received promptly, and a critical
value requires immediate intervention.
(Option 4) Even if the HCP usually makes rounds early in the morning, a critical value requires
immediate, real-time notification to prevent delay of potentially urgent intervention.
Critical laboratory results, such as positive blood cultures, require immediate communication
with the health care provider (HCP) and timely intervention for client safety. The nurse must
contact the HCP directly as soon as possible to avoid life-threatening complications (eg, septic
shock).
A nurse is providing anticipatory guidance to a client with early Alzheimer disease and
osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is
the best example of an educational goal for anticipatory guidance?
Anticipatory guidance prepares clients and caregivers for future health needs and is useful

throughout life, from pediatric growth and development to anticipated changes related to disease
processes. This type of education promotes health and helps to reduce client/caregiver stress and
anxiety, which heighten with unexpected cognitive, physical, and emotional changes.
Anticipatory guidance educational goals should be client-oriented, realistic, objective,
measurable, and focused on preparing for future needs specific to the client.
The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease
progression. In the early stage, the client can make changes in the home to promote safety in the
future (Option 3).
(Option 1) Memory aids (eg, pill organizers, alarms) should be used now, while the client has
only mild cognition changes. As the disease progresses, a caregiver should take over medication
management.
(Option 2) Support groups are an appropriate intervention for current psychosocial needs (eg,
depression).
(Option 4) Clients with osteoarthritis are at risk for nutritional deficits due to functional decline
(eg, inability to open jars), and clients with Alzheimer disease can forget to eat. The nurse
should address this current need by teaching simple meal planning.
Anticipatory guidance addresses expected changes related to growth and development or disease
progression. Educational goals should be client-oriented, realistic, objective, measurable, and
focused on preparing for future needs specific to the client.
The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be
assigned to a semi-private room?
Although placing pediatric clients of different sexes in a semi-private room is not ideal, the
charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5,
the male-female pair can room together. The client in Buck traction does not have a
transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given
the options above, this is the safest room assignment.
(Option 2) Children with infections requiring airborne precautions (eg, varicella, tuberculosis,
measles) should be placed in a private, airborne infection isolation room (eg, negative airflow
room). If required, clients infected with the same organism can be roomed together, but a private
room is preferred.
(Option 3) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The
risk for cross contamination is high, especially with caregivers sharing the facilities.
(Option 4) A client with sickle cell anemia is at risk for infection due to spleen dysfunction
(repeated infarctions), and a client with periorbital cellulitis has an infection. Although
compatible in age and sex, these clients should not share a room.
Pediatric room placement should be based on disease process, sex, and developmental stage.
When assigning children to semi-private rooms, the charge nurse must consider client safety
first.
After talking to the client, the health care provider (HCP) tells the registered nurse that the
client's signature is needed on the consent form that has been filled out. While the nurse is
obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that
I'll be on after the cholecystectomy." What action should the nurse take?
The HCP performing the surgery should explain the risks, benefits, and alternatives of the
specific procedure to the client. However, the nurse can witness the client's signing of the
consent form; this differs from "obtaining consent."
If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the
HCP should be contacted to provide additional teaching to the client. However, an ordinary
question about general care or health care teaching can be answered by the nurse as this is part of
the nurse's role.
(Options 1, 2, and 4) As the client is not asking about details related to the procedure, it is
unnecessary for the HCP to return to talk to the client (unless the client specifically asks for
this). The client's question does not interfere with the ability to legitimately sign consent for the
procedure or with the nurse's witnessing of the client signing the consent form.
It is the HCP's responsibility to obtain informed consent and explain the procedure's risks,
benefits, and alternatives to the client. The nurse can witness the client's signature and provide
normal teaching. If the client has a question about the proposed procedure/surgery, the HCP
should return and provide additional teaching.
During the charge nurse's morning rounds, a client says, "I hope you will take better care of me
than the nurse I had last night." What should be the charge nurse's initial response?
The first step in management issues, just as in nursing care, is assessment. The charge nurse
must first determine what happened before deciding the next course of action. The client could
have misperceived certain actions (Option 2).
(Option 1) It is important to determine what happened before apologizing for any staff
behavior. The charge nurse could issue a "blameless apology" ("I'm sorry you are upset" or "I'm
sorry you think you did not receive what you needed last night"). However, the option indicates
an apology for the nurse's treatment, which may have been appropriate. The charge nurse needs
a description of what occurred in order to take action against misperceptions or inappropriate
staff behavior.
(Option 3) This statement might be true but does not rectify the situation. The client's concern
may be related to something, such as tone of voice, not directly related to client load.
(Option 4) Until the charge nurse understands the client's issue with care the previous night, the
nurse cannot realistically say that things will be different or better today. That is false
reassurance.
When a client complains about staff treatment, the first response should be to assess the client's
perceived wrong. The nurse can then determine what follow-up action is needed.
A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the
unlicensed assistive personnel (UAP) reports that another client is requesting medication for
postoperative pain. What is the nurse's most appropriate action?
The nurse can prioritize care according to the degree of urgency, the extent of threat to the
client's survival, and the potential for complications. At this time, the other client's pain issue is
of medium urgency and does not pose an immediate threat to survival. The most appropriate
nursing action is to inform the postoperative client that you will be there shortly, and complete
changing the sterile dressing (Option 3).
Interrupting the sterile dressing change for a client with an infected wound puts the client at risk
for injury, as microorganisms can invade the uncovered wound. However, if the dressing change
were lengthy, the nurse could delegate the task of medicating the postoperative client to another
nurse (Option 4).
(Option 1) Although taking vital signs when a client reports pain is appropriate, evidence
indicates that vital signs are unreliable physiologic indicators for pain.
(Option 2) The UAP is instructed to ask the client if they are having pain and then report back
to the nurse. However, the registered nurse is responsible for pain assessment and should not
delegate this task to the UAP.
A nurse can prioritize client needs and problems according to the degree of threat to the client's
survival and the potential for complications. The nurse uses clinical judgment to decide which
client situation requires immediate attention and which one can wait.
The nurse reads a journal article about a study using a new pain management protocol for clients
with terminal cancer. What should the nurse first consider in determining whether the protocol
is appropriate to implement on the unit?
When evaluating research for practice changes, the nurse must first determine if there is
reasonable similarity between the nurse's unit population and the study population to expect
equivocal results. This should be the initial consideration to ensure that the research is
appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute
pain, the protocol for adult clients with terminal cancer might not translate effectively or safely
to those clients.
Other aspects of the study to evaluate include whether all clinically relevant outcomes were
addressed, if the benefits outweigh any potential harm or costs, and if the protocol resulted in
improved care.
(Option 1) An institutional review board (IRB) is a committee that reviews research before it is
conducted to ensure that is it ethical. Legally, any study of human subjects needs IRB approval
to provide protection from unnecessary risk. Peer-reviewed journals usually require a statement
of IRB approval before accepting an article for publication. However, the IRB process does not
determine whether the findings are relevant for a particular setting.
(Option 3) The educational credentials of a researcher may be relevant, especially if a non-
health care professional has conducted a health care study. However, the integrity of the
research process and findings is more important than the holding of any particular degree.
(Option 4) Financial support can be considered, particularly when research finds favorably for a
drug or product that is manufactured or supported by a sponsor of the study. Although it is
essential for a financial relationship to be disclosed, that alone does not negate the usefulness of
the study.
When seeking to apply research findings in practice, the nurse should consider the similarities
between the research study population and the client population.
The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation
of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level
of the client's chest during the ambulation down the length of the hallway. What action should
the RN take initially?
The Foley bag is too high and needs to be lowered. When observing a provider making an error,
the RN should immediately intervene to stop any potential harm to the client. It is important to
timely correct a staff member who is making a mistake to help ensure that the error is not
repeated. Correction of staff should always be done privately, not in front of the client.
(Option 1) Future inservice education is not a timely solution to this immediate need. It is
appropriate to carry out teaching first rather than initiate disciplinary actions. According to the
Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident
does not need to be reported.
(Option 2) The most important issue needing intervention is the improper positioning (too high)
of the Foley catheter bag. Positive reinforcement for appropriate actions can also be included
(and is beneficial), but the error should first be corrected to prevent harm.
(Option 4) It is important to attend to the error right away to help ensure that the UAP does not
repeat it. Letting this UAP complete assigned tasks first does not immediately deal with the
incorrect position of the Foley bag and may not effectively teach (aid retention of) the correct
positioning to the UAP.
When observing a provider making an error, correct it immediately to stop any potential harm to
the client. Correct the provider privately and as soon as possible.
The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by
unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that
apply.
Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP)
when it is deemed safe and appropriate. The nurse must provide UAPs with detailed
instructions, including when to move the client, which techniques to use, and when to use
assistive persons or devices. The nurse must also notify UAPs of any client mobility
restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for
repositioning or moving (Option 4).
The client who is 8 hours postoperative total hip replacement requires assessment prior to
repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain
abduction; nursing judgment is required (Option 1).
To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using
the following guidelines:
 Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option 2).
 Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist
(eg, comatose, medicated) (Option 3).
 Use a full-body sling lift to move/transfer nonparticipating clients.
 Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg).
 Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91
kg) (Option 5).
Client repositioning and transferring can be delegated to unlicensed assistive personnel if it is
deemed safe and appropriate. The nurse must provide instructions to maintain client safety and
intervene if the task is performed inappropriately or requires nurse involvement (eg, spinal cord
stabilization).
Which statements involve acceptable use of an abbreviation, symbol, or dose designation in
documentation? Select all that apply.
The Joint Commission (2004) and Institute for Safe Medication Practices prohibit error-prone or
"dangerous" abbreviations, descriptions of symptoms, and dose designations in medical
documentation.
"Cm" (centimeters) and "II" (2) (eg, decubitus staging) are acceptable
abbreviations/notations (Option 1).
The abbreviations "ac" (before meals), "pc" (after meals), and "c/o" (complains of) are
acceptable (Option 4).
"QID" (4 times a day) is acceptable. Abbreviations that are not acceptable include "qd" (daily)
and "q1d" (daily), which can be mistaken for "qid" (4 times a day), and "qod" (every other day),
which can be mistaken for "qd" (daily) (Option 5).
(Option 2) A trailing zero after the decimal point is not acceptable as it could be interpreted as
40 instead of 4 if the decimal point is not noted. The use of "u" for unit is not acceptable as it
can be mistaken for the number 0 or 4 (eg, 4u seen as 40). "SSRI" (sliding-scale regular insulin)
is not acceptable to indicate insulin as it can be mistaken for selective serotonin reuptake
inhibitor. "Mg" for milligrams is acceptable.
(Option 3) A zero must precede the decimal dose. If the decimal point is missed, ".5" could be
mistaken for 5 mg.
Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations
include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero
before a decimal dose and no trailing zero after a decimal point.
Which guiding principle is suitable for dealing with a disaster scenario involving radiation
contamination?
The key aspects related to radiation exposure are time and distance. The greater the distance,
the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent,
manifest, and recovery or death. Initially, all victims will appear well; however, the damage is
mainly internal, leads to cell destruction, and manifests later on.
Victims farthest away from the radiation source are the most salvageable. In this scenario, the
principle of disaster nursing is to do the most good for the most people with the available
resources.
(Option 1) Nerve agents used as biological weapons (eg, sarin) inhibit acetyl-cholinesterase,
and their effects are caused by the resulting excess acetylcholine. Common symptoms are
miosis, rhinorrhea, copious secretions, shortness of breath, and flaccid paralysis. Treatment is
with suction and support ventilation and circulation. However, these symptoms are not related to
radiation contamination.
(Option 3) Damage from radiation affects the most radiosensitive cells first; these are the
hematopoietic, digestive, central nervous system, and cutaneous cells. The presence of severe
symptoms indicates extensive internal damage and that the victims are less salvageable in the
long term.
(Option 4) Neurologic symptoms such as symmetrical descending flaccid paralysis with cranial
nerve palsies (ptosis, diplopia, dysphagia, dysphonia) are classic of botulism, which is caused by
toxins from the spore-forming anaerobic bacillus Clostridium botulinum. Treatment includes
ventilator assistance and the heptavalent botulism antitoxin.
In triaging victims from a radiation contamination disaster, nurses should assist clients who are
farthest away from the source and have the least symptoms as most damage is internal and will
not be apparent initially. Nerve agents (eg, sarin) cause excess acetylcholine with copious
secretions. Neurologic symptoms are classic for biological threats such as botulinum toxin.
The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room
should the nurse assign to a client being transferred from the post anesthesia recovery unit
following a total knee replacement?
A client who is postoperative total knee replacement is at risk for infection. No postoperative
client should be assigned to a room with a client who has an actual infection or the potential for
infection.
This client should be assigned to room 4 as the client with the cast has the lowest potential risk
for infection (Option 4).
(Option 1) This client has erythema at the pin sites; this can be a sign of infection, a
complication of skeletal traction.
(Option 2) This client has cellulitis, a bacterial infection of the skin, and osteomyelitis, an
infection of the bone.
(Option 3) This client has a fasciotomy wound, which is usually kept open for several days to
relieve the pressure in the myofascial compartment. This client is a potential source of infection
and is susceptible to infection as well.
A client who is postoperative total knee replacement is at increased risk for infection. This client
should not be assigned to a room with a client who has an actual (eg, cellulitis, osteomyelitis) or
potential (eg, skeletal traction, fasciotomy) infection.
Which client should the charge nurse assign to the room closest to the nurses' station?
The client with dementia and gastroenteritis presents the greatest safety risk, which includes
potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room
closest to the nurses' station as a confused client requires frequent checks and this allows the staff
to respond quickly if necessary.
(Option 1) The nurse will instruct the client who is deaf on the proper use of the call system.
Staff should be instructed to answer this client's call light immediately. Notes to communicate
that there was an immediate response to this client's call should be posted at the nurses' station as
well.
(Option 3) Meeting the needs of a client in airborne isolation safely is not dependent on
proximity of the client's room to the nurse's station. The staff should assess the client with the
same frequency even if the client is in the room furthest from the nurses' station.
(Option 4) The client requiring frequent intravenous pain medication can rest best in a quiet
location that is further away from the nurse's station. Proximity to the nurses' station does not
affect the frequency of pain assessment, administration, and assessment of response to analgesia.
When assigning rooms, the nurse should consider infection control, physical location, acuity
level, and individual client safety needs. Cognitive impairment and fluid and electrolyte
disturbances pose the greatest risks to a client's safety.
There has been a large-scale community disaster and clients must be roomed together at the
hospital. Who are appropriate roommates in light of infection risk principles? Select all that
apply.
PID is an acute infection of the upper genital tract. The most common organisms
are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same
room. There is no infection risk for a client with gastrointestinal bleeding (Option 4).
Clients with the same organism can room together (Option 5).
(Option 1) Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact
precautions also if open lesions are present). Pertussis requires droplet precautions. Both the
precautions and the organisms are different, and the clients could cross-infect each other.
(Option 2) An AIIR (formerly negative-airflow room) is indicated when the client has an
organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the
room with a client with this type of infection, especially one with a significant co-morbidity.
(Option 3) Chemotherapy causes bone marrow suppression with immunosuppression.
Although the client may not need reverse or protective isolation (eg, when absolute neutrophil
count is ≤500/mm3), an infectious client should not be placed with this client. Yellow sputum
typically indicates bacterial infection. COPD clients can have chronic colored sputum, but
infection (bacterial or viral) is the primary cause of exacerbations (the most likely reason the
client is in the hospital). This is not a safe option.
For infection control, clients with same organisms can be placed together. Infectious clients
cannot be placed with immunosuppressed or at-risk clients.
The charge nurse in the coronary care unit must transfer a client to the medical unit to
accommodate another acutely ill client from the emergency department. The nurse suggests the
transfer of which client to the health care provider?
Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions
to provide symptom and pain relief and psychological and spiritual support, rather than on
curative interventions. The client with end-stage heart failure, a terminal illness, would be most
appropriate to transfer as palliative care can be provided in any health care setting.
(Option 1) Cardiac troponins are proteins released into the blood by damaged cardiac muscle
(ie, myocardial infarction). Serial troponin I levels are normal (<0.5 ng/mL [0.5 mcg/L]) in
clients with unstable angina as there is no muscle injury; however, cardiac ischemia is present.
This client requires continual cardiac monitoring and interventions to restore blood flow to the
heart.
(Option 2) Atrial fibrillation involves the rapid firing of irritable foci in the atria and an
irregular, sometimes rapid, ventricular response. To slow the heart rate (goal <100/min), an IV
infusion of the calcium channel blocker diltiazem (Cardizem) is prescribed; this requires
continual cardiac monitoring.
(Option 3) Complete heart block is life-threatening and requires a pacemaker. This client
should not be transferred.
Clients with unstable angina experiencing chest pain and clients newly admitted with complete
heart block or atrial fibrillation with a rapid ventricular response are unstable and require
continual monitoring in an intensive care unit.
A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and
weight loss. The client lives in the child's home, but the nurse is questioning the safety of the
home. The nurse needs to assess the appropriateness of the living situation and arrange for an
alternate living situation or additional support if needed. It is most appropriate for the nurse to
consult with which interdisciplinary team member during the assessment?
An important part of the nursing role is to advocate for the health and safety of the client. This
client has fallen and lost weight when living in the child's home, prompting the nurse to advocate
for the client by bringing in other members of the interdisciplinary team to assess the home
situation.
When a nurse is concerned about the client's living situation, the social worker is the most
appropriate team member to consult with first. The role of the social worker includes assessing
the client's living situation and arranging for an alternate living situation or support services as
needed.
(Option 1) Adult protective services would be notified when abuse or neglect is suspected. In
the hospital setting, a social worker should be contacted to do a detailed assessment of the
situation before adult protective services is notified.
(Option 2) The physical therapist should be consulted when there is concern about the client's
ability to function safely in the home environment.
(Option 3) The physician would not be the most appropriate person to appoint when a detailed
assessment of the home living situation needs to be conducted. However, the physician should
be notified if a social worker is assigned to assess the home living situation.
Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary
team members, such as the social worker. Advocacy is especially important in younger and
elderly clients and those who are cognitively challenged or have mental health concerns.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make
room for newly admitted clients. Which client would the nurse identify as safe to recommend
for discharge?
Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies
clients who are safe to recommend for discharge to make room for newly admitted clients.
A client with acute asthma exacerbation may require treatment in the emergency department or
hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be
discharged home when respiratory status has stabilized and continue the previous home regimen
of inhaled bronchodilators and corticosteroids (Option 2).
(Option 1) Clients who have received chemotherapy may be immunocompromised due to
neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close
monitoring and antibiotic therapy are required.
(Option 3) Clients with diabetes may develop diabetic ketoacidosis (DKA) during illness or
infection. Features of DKA (eg, lethargy, abdominal pain, hyperglycemia, urine ketones) are a
medical emergency. Untreated DKA may progress to loss of consciousness and coma.
Treatment includes frequent laboratory monitoring and IV insulin, fluids, and potassium.
(Option 4) Clients with ulcerative colitis are at risk for developing toxic megacolon (ie, severe
inflammatory colon distension). Symptoms include fever, nausea, vomiting, pain, and
abdominal distension. Clients require close monitoring, nasogastric tube for decompression, IV
fluids, and antibiotics. Emergency surgery may be required.
In response to a local disaster, the nurse identifies clients who can be safely discharged to make
room for newly admitted clients. A client with acute asthma exacerbation can be safely
discharged home when respiratory status has stabilized.
A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for
lateral violence and bullying among staff. Which actions will the nurse educator include in
teaching about what staff members should do if they experience workplace violence? Select all
that apply.
Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried
out by a co-worker against another co-worker and designed to control, diminish, or devalue a
colleague. These behaviors usually take the form of verbal abuse such as name-calling,
unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help
someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral
violence.
Violence in the workplace should not be tolerated or ignored by either staff or management.
Actions that staff members can take if they become victims of lateral violence include:
 Documenting and keeping a file of all incidents (Option 1)
 Reporting the incidents to the immediate supervisor
 Letting the bully know that the behavior will not be tolerated (Option 5)
 Observing interactions between the bully and other colleagues (may validate the victim's
experiences and serve as a source of support) (Option 3)
 Seek support from within the facility or from an external source
(Option 2) Ignoring acts of lateral violence will perpetuate the bullying.
(Option 4) The chain of command should be followed when reporting incidents of lateral
violence. If the immediate supervisor takes no action, the employee can move up the chain.
Lateral violence in the workplace (acts of aggression by an employee toward another employee)
should not be tolerated or ignored. Victims can take action against bullying, including
documenting and reporting incidents, standing up to the bully in a professional way, and seeking
support.
The nurse is caring for a client who is participating in a research study (randomized controlled
trial) of a new medication. Which statement indicates that the client has an appropriate
understanding of the study and reason for participation?
Research with human subjects is reviewed by institutional research boards to ensure ethical
principles are followed. The research participant cannot be deceived and must participate
voluntarily knowing the risks and purpose of the study; confidentiality must be maintained.
Clients in research studies often have altruistic motives. They know they may achieve no
personal gain, but others could benefit from their participation.
(Option 1) A basic tenet of any research study is that the client has the right to autonomy and to
withdraw at any time.
(Option 3) All clients should receive safe, quality care whether they participate in the study or
not. Due to randomization, the client has no guarantee of receiving a medication that is more
effective rather than the placebo. This misconception should be clarified.
(Option 4) Clients should not be coerced in any way, including withdrawal of approval or
affection. The client may have misperceived the HCP's potential response, but this stated reason
for participation needs further exploration.
Quantitative research studies involving humans must use ethical principles, including that the
client cannot be coerced into participation and has the right to withdraw at any time.
The nurse reviews the serum laboratory results of assigned clients. Which results are most
important to report to the health care provider? Select all that apply.
Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg,

lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan)
cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia
(Option 4).
Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections.
The nurse should monitor renal function and peak and trough levels, and report an elevated
creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse
effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval
may be required (Option 5).
(Option 1) Neutropenia (decreased neutrophil count) increases a client's susceptibility to
infection. Filgrastim (Neupogen) is used to increase the neutrophil count in clients with certain
malignancies and in those undergoing chemotherapy. Neutropenia is expected in this client and
is not the most important result to report.
(Option 2) Acute osteomyelitis, an infection of the bone, is characterized by local and systemic
manifestations of infection (eg, leukocytosis - white blood cell count >11,000/mm 3 [11.0 x
109/L], increased erythrocyte sedimentation rate, fever) and involves long-term antibiotic
therapy. This is expected and is not the most important result to report.
(Option 3) Acute pancreatitis is an acute inflammation of the pancreas, characterized by
abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced
by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl). Morphine can
also be used; worsening pancreatitis due to an increase in sphincter of Oddi pressure has not been
proven in studies. Elevated lipase level is expected and is not the most important result to report.
ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can
cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin,
gentamicin, amikacin) can cause nephrotoxicity.
The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate
registered nurse (RN) during orientation. The LPN states, "The only difference between you and
me is the size of our paychecks." What would be the best response for the new graduate RN to
make initially?
Team building involves recognizing that everyone has personal strengths and specific skill sets
that together can be used to provide quality client care. The new graduate should recognize the
contributions of the LPN and give respect to the LPN rather than initially be confrontational.
Emphasizing common goals, such as safe, quality client care, is usually more effective than
debating personnel qualifications.
(Option 1) The LPN knows that the RN is the manager. This response might have been
appropriate if the LPN had refused a direct delegation or showed some other disregard of the
RN's team management. The RN should focus on the value the RN has for the LPN.
(Option 2) The LPN knows that the RN has more education. The real need is not to clarify
educational preparation. The RN must focus on the common good rather than argue. The LPN
could be making this statement due to feeling threatened, disrespected, or underappreciated.
Demonstrating respect and willingness to use the LPN's strengths is more effective in team
building.
(Option 3) The LPN knows that they have different scopes of practice. This response might
have been appropriate if the RN had found the LPN doing something outside of the LPN's legal
scope of practice. The RN needs to focus on the common good rather than reemphasize the
obvious.
When initially confronted by other team members about qualifications or experience, the RN
should emphasize the common goal of working toward safe, quality client care.
During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed
assistive personnel (UAP) is totally incompetent. What is the best response for the day charge
nurse to give?
Incompetency is a concern for client safety and quality care. The nurse manager is responsible
for hiring/firing and setting up additional training times or experiences for staff. The situation
should be discussed with the person who has 24/7 responsibility for the unit so that an
appropriate response can be given to the night nurse's perceptions (Option 4).
(Option 1) The night nurse can provide task-specific instructions/training, but incompetence
implies a global dysfunction beyond minor, on-the-job, intermittent instructions. In addition,
other factors could be involved that may be influencing the UAP's behavior, such as personal
issues or impairment from substance abuse. It is best to discuss this situation with a higher
authority to determine the best approach.
(Option 2) This response is something the night nurse knows. The need is to decide the next
action. The scope of this problem is probably beyond the night nurse's responsibility and
authority.
(Option 3) This response may be true. However, the bottom line is finding out if the UAP's
performance is of adequate quality and safe for clients. The amount of effort that the caregiver is
expending is not the bottom line.
When a caregiver's performance is below the standard of care needed to provide safe and quality
care to clients, the appropriate authority should be notified so that the situation can be handled.
The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for
IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option
for this client?
Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in
clients with diabetes mellitus. Room 2 is the best assignment option for this client with
cellulitis. The client with dementia and urinary incontinence who has an external urinary
condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4.
(Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical
procedure with small incisions) is at increased risk for infection. The client with cellulitis should
not be placed in room 1.
(Option 3) Although this client has pulmonary embolism, the history of
prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need
vaccination against encapsulated organisms (eg, pneumococcus, meningococcus,
and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these
clients. The client with cellulitis should not be placed in room 3.
(Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus
(SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The
systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its
progression increase infection risk. The client with cellulitis should not be placed in room 4.
A client with an infection should not be assigned to a semi-private room with a client who had
surgery or is immunocompromised and receiving immunosuppressants as these clients are highly
susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis.
Which are appropriate examples of cost-effective care? Select all that apply.
Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying
a new dressing, when sterile technique is commonly used). The gloves need to be removed and
changed prior to application of a new dressing. There is no need to use the more expensive
sterile gloves.
The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile
field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it
wet, do not reach over it).
(Option 3) Once supplies have been in a client's room, they are "contaminated" and cannot be
returned to a central source or used on other clients. They can be sent home with the client for
the client's own use.
(Option 4) Tourniquets should be for single client use. They should not be shared as there is a
risk of cross-infection, even if contamination is not visible.
(Option 5) Pour bottles and IV bags with sterile solutions have no preservative and must be
changed every 24 hours after being accessed. After 24 hours following opening a bottle of
sterile saline, the solution is considered contaminated and must be discarded, even if there is still
unused solution in the container.
Use clean, rather than sterile, gloves when removing contaminated dressings. The inside of a
sterile glove wrapper is sterile. Do not return items in clients' rooms to central supplies, discard
sterile solution after 24 hours, and do not reuse tourniquets between clients.
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which

illustrates the best use of an interpreter to explain the situation to the client? Select all that
apply.
Clients from many cultures will be more responsive if the interpreter is the same gender,
especially when the condition is highly personal or sensitive (Option 2).
The nurse should maintain good eye contact when communicating with the client. The
interpreter should translate the client's words literally. Communication is with the client, not the
interpreter. The nurse should use basic English rather than medical terms, speak slowly, and
pause after 1-2 sentences to allow for translation (Option 3).
Providing simple instructions about upcoming actions in the order they will occur will be easier
for the client to understand. For example, the nurse can indicate that there will be surgery and
then a follow-up visit as opposed to, "You'll follow up with the health care provider after your
procedure" (Option 5).
(Option 1) The nurse should obtain feedback to be certain that the client understands. This
feedback should extend beyond nodding as some people nod to indicate that they are listening or
nod in agreement to "save face" even though they do not understand. It is better to use a tactic
such as having the client repeat back information (which is then translated into English).
(Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual
employee is not available. The client may not want the friend/relative to know about this
personal situation, or the person may not be able to adequately translate medical concepts and/or
understand client rights.
When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex
individual rather than a family member or personal friend. The nurse should speak slowly and
directly to the client, not the interpreter; provide information in the sequence it will occur; and
obtain feedback of comprehension beyond merely nodding.
The charge nurse must assign a room for a client who was transferred from a long-term care
facility and is scheduled for extensive surgical debridement to remove infected tissue from an
unstageable pressure injury. Which room assignment is the most appropriate for this client?
Surgical debridement of an unstageable pressure injury involves using a scalpel

to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most
appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed
and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A
and B (Option 3).
(Option 1) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells
(monoclonal antibodies), which are ineffective in providing protection against infection and
suppress normal bone marrow cell production (eg, erythrocytes, platelets, leukocytes). This
client in Room A is especially vulnerable to infection due to immunosuppression related to the
disease process and to drug therapy with corticosteroids.
(Option 2) The postoperative client should not be assigned to Room B with a client who has
osteomyelitis, an infection of bone.
(Option 4) The client with influenza requires droplet precautions and would likely require a
private room (Room D). Clients with severe disease (ie, requiring hospitalization) should
receive antiviral medication (eg, zanamivir, oseltamivir) as they are at high risk for
complications.
A client undergoing an extensive surgical debridement for an infected pressure injury should not
be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or
who has an active infection.
Unstageable pressure injury

Common applications
Personal protective equipment
of droplet precautions
 Neisseria meningitidis  Surgical mask

 Haemophilus influenzae type B  Private room
 Diphtheria  As needed for procedures with
risk of splash or body fluid
 Mumps
contact: gloves, gown,
 Rubella goggles/face shield
 Pertussis
 Group A Streptococcus (strep throat)
 Viral influenza
A client is receiving several adjunctive professional therapies while rehabilitating after a stroke.
Which client statements indicate an understanding of the services? Select all that apply.
Several adjunctive professional services assist clients in the post-acute phase of their illness as
part of an overall interdisciplinary team. Speech therapy focuses on speech and
communication but also on swallowing/eating issues (Option 4). A client with a stroke will
need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-
down positioning, chewing on the non-affected side of the mouth). Social workers assist with
developing coping skills, securing adequate financial resources or housing, and making referrals
to volunteer organizations (Option 3). Wound care is a resource for assessing and planning the
optimal care of any wound (Option 5).
(Option 1) Occupational therapy emphasizes the skills necessary for activities of daily living
(eg, dressing, bathing, cognitive or perception issues); however, walker training is performed by
a physical therapist. An overly broad generalization is that occupational therapy is for "above
the waist."
(Option 2) Physical therapy focuses on mobility, ambulation, ability to transfer, and use of
related equipment. An overly broad generalization is that physical therapy is for "below the
waist." Dressing skills would be taught via occupational therapy.
Some of the adjunctive professional services in post-acute care include wound care (eg,
assessing/planning wound treatment), speech therapy (eg, communicating, swallowing, eating),
social work (eg, coping, connecting to resources), physical therapy (eg, mobility, ambulating,
using equipment), and occupational therapy (eg, activities of daily living).
Which client event would be considered an adverse event and would require completion of an
incident/event/irregular occurrence/variance report? Select all that apply.
Adverse event is an injury to a client caused by medical management rather than a client's
underlying condition. It may or may not be preventable. The Institute of Medicine (2000)
recognizes 4 types of errors. They are:
 Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results
of monitoring)
 Treatment (error in performance of procedure, treatment, dose; avoidable delay)
 Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of
treatment)
 Other (failure of communication, equipment failure, system failure)
Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury.
The risk fall assessment should be adjusted. Option 5 is an avoidable delay in application of a
test, which will affect timely diagnosis. The nurse should advocate for a more timely completion
of the test. Option 2 is a failure to provide appropriate treatment and has a direct correlation for
worsening cellulitis.
(Option 1) Failure to complete an ideal nursing care plan is not an adverse event. Hospitals
have policies that allow medications to be given within a range (usually 30-60 minutes) of the
due time. It could be an issue if the treatment was significantly out of the time range or omitted
completely.
(Option 3) The client's seizure is most likely related to an underlying condition rather than a
medical management error.
Adverse events cause injury that is related to medical management, not the client's underlying
condition. Identified areas are diagnostic, treatment, preventive or failure of communication, and
equipment or other systems. Adverse events include falls, unreasonable delay in diagnostic tests,
and failure to provide a prescribed treatment.
The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal
responsibility with regard to informed consent? Select all that apply.
Written consent is required for invasive procedures and surgery. Clients must be informed of
and competent to understand information about the procedure, alternate treatments, and risks.
They must also be informed that they have the right to refuse the procedure or surgery.
The nurse's role in informed consent is to witness that the client signed the consent voluntarily
and was competent at the time of signing (Options 1 and 5). The nurse should ensure that the
client received necessary information and has no remaining questions about the procedure. After
obtaining the signature, the nurse should document in the client's medical record that the
informed consent was given and the date/time of the signature (Option 2).
(Options 3 and 4) The health care provider is responsible for explaining all aspects of the
procedure, ensuring that the client has a correct understanding of the procedure and its potential
risks, providing the names/qualifications of those who will be involved, describing available
alternate treatments, and reinforcing that the client has the right to refuse the procedure. The
health care provider should be contacted if the client does not have a correct understanding of the
procedure. The nurse should not try to explain procedures as he/she could be held liable for
giving incorrect/incomplete information.
The nurse's role in informed consent is to witness a client's signature and ascertain that the client
signed voluntarily, was competent to provide consent at the time of signature, received the
necessary information, and has no further questions.
A Native American client is hospitalized for depression and attempted suicide. Family members
have requested that they be allowed to bring in a medicine healer to perform a ritual on the
client. Which of the following is the best action by the nurse?
The medicine healer, or shaman, is an important component of Native American culture and is
often consulted by both clients and HCPs when a client is ill or hospitalized. The medicine
healer uses a variety of practices, including herbs, plants and roots, singing, and healing
ceremonies.
The medicine healer needs to be included in this client's treatment. Making arrangements for the
healing ritual gives credibility and respect to the client's cultural beliefs and ensures that the
client's spiritual needs will be met. In providing culturally sensitive care, the nurse needs to
recognize and be tolerant of various practices associated with beliefs that are different from those
of traditional Western medicine. Denying the medicine healer the opportunity to perform a ritual
could interfere with the client's response to therapy.
(Option 1) Although it may be true that the client's depression is being treated with
antidepressants, the medications do not meet the client's spiritual needs.
(Option 2) This response demeans the client's beliefs and does not acknowledge the importance
of the medicine healer to the client's health.
(Option 4) Allowances and accommodations should be made by health care facilities to ensure
that clients' spiritual needs are met.
Medicine healers, or shamans, are an important component of Native American and other
cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that
clients' spiritual needs are met and may contribute to the healing process. The nurse needs to
recognize and be tolerant of health practices and beliefs that are different from those of
traditional Western medicine.
The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse
describes various roles of the interdisciplinary team. In which situations would the nurse "case
manager" be consulted? Select all that apply.
Case management involves assessing, planning, facilitating, and advocating for client health
services to accomplish cost-effective quality client outcomes. This is done through
communication and use of available resources. A professional nurse often serves in the case
manager role. The case manager in the hospital setting assesses client needs, decreases
fragmentation of care (Option 2), helps to coordinate care and communication between
HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for
home health or placement after discharge (Option 4).
(Option 3) Case managers typically do not provide direct client care. Medication reconciliation
should be done between the primary nurse directly caring for the client and the HCP.
(Option 5) Case managers often make daily rounds to the nursing department to review
documentation in the client's chart but do not necessarily visit the client personally.
The nurse providing direct client care should be familiar with the nurse case manager role as part
of the interdisciplinary team. The goal of the nurse case manager is to facilitate provision of
quality care across a continuum, decrease fragmentation of care across various settings, and
contain costs.
The risk management nurse is reviewing client records. Which nursing intervention could have
contributed to a sentinel event?
A sentinel event is any unanticipated event in a health care setting that results in death or serious
physical or psychological injury.
Warfarin is an anticoagulant often used in clients with the following:
 Atrial fibrillation (to prevent clot formation and reduce the risk for stroke)
 Deep venous thrombosis and pulmonary embolism (to prevent additional clots)
 Mechanical heart valves (to prevent clot formation on valves)
The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of
warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves),
the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk.
The nurse should not administer warfarin if the INR is over 4.
(Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose.
(Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is
given to prevent hypoglycemia. This is an appropriate action.
(Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies.
The target International Normalized Ratio (INR) for most conditions in which warfarin is used is
normally 2-3 and is occasionally 3.5. The risk of bleeding increases as the INR rises.
A client with a 10-year history of methadone use for chronic leg pain is being treated with
azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the
QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be
discharged against medical advice to return home and take the client's own medications to
prevent going into withdrawal without the methadone. Which is the most appropriate nursing
response?
When clients are hospitalized, they lose control of many things, including their medication
management. This loss of control can be frightening for the client, especially one who has had
control of medications for many years.
This client, who has a decade of experience taking methadone for chronic pain, is afraid that
suddenly stopping this medication may precipitate withdrawal. The client is trying to regain
control and avoid this problem by leaving the hospital against medical advice. However, the
client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote
negotiation between the client and HCP to develop a plan of care that will address the concerns
of each. The plan should advocate for the client to ensure that the concerns are addressed.
Care planning should be a collaborative, shared process informed by the knowledge and
preferences of the client and evidence-based recommendations by the HCP that are appropriate
to the situation.
(Option 2) This response is based on the idea of the nurse and HCP being in control, but it fails
to include the client in the decision-making team.
(Option 3) This statement provides a rationale for the client to remain in the hospital, but it does
not address the client's concerns about going into withdrawal.
(Option 4) This response is based on the idea of client autonomy, but it does not propose a
solution to the problem.
A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs,
and preferences, and the expertise and evidence-based recommendations of HCPs.
Which issue would a unit quality improvement committee address?
A unit quality improvement committee assesses process standards (guidelines, systems, and

operations) and clinical issues on a specific unit that affect delivery of client care and client
outcomes. The committee implements a process to improve performance if the standards are not
being met.
Examples requiring unit quality improvement include the following:
1. Medications prescribed STAT are not available in a timely manner
2. Catheter-associated bacterial infections are increasing within the unit (Option 3)
(Option 1) The issues addressed by a unit quality improvement committee should be related to
standards and clinical factors involving the specific unit rather than client perception.
(Option 2) Individual practice issues or concerns (eg, individual performance, financial
reimbursement) would be addressed by the nurse's manager or appropriate hospital committee
(eg, peer review committee).
(Option 4) Although workplace hostility can potentially affect staff perceptions and
performance, personnel issues should be addressed by the specific department manager (eg,
laboratory personnel management) or human resources.
A unit quality improvement committee assesses clinical issues arising on a unit (eg, increased
infection rate) and problems with the systems and standards (eg, late delivery of medications
from pharmacy) created to ensure delivery of quality care. This committee is not concerned with
administrative or management issues (eg, client satisfaction surveys, individual performance
reviews).
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the
client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to
determine the cause of the obstruction and possible causes include intestinal adhesions and
ovarian or colon cancer. The surgeon asks the child to translate this information for the client
and assist with translating the consent form. Which is the most appropriate action by the
nurse?
The nursing role in advocating for the client includes ensuring the use of interpreters for clients
who speak a different language, particularly during the informed consent process. The person
interpreting for the client should ideally possess the following:
 Training in medical terminology and procedures
 Ability to protect the client's rights in a medical setting
 Fluency in the language
 Understanding of cultural beliefs and nuances
For these reasons, and to protect client confidentiality, family members should not be used as
medical interpreters unless the situation is urgent and a family member is the only one available
to fill this role.
(Option 1) The nurse may act as a witness, but this is less important than ensuring appropriate
resources are used to carry out the informed consent process.
(Option 2) The nurse is responsible to provide preoperative teaching, but this is less important
in this situation than ensuring that an appropriate informed consent process is followed.
(Option 3) The use of family members as translators of medical information is not ideal but
may be used when necessary, particularly when a situation is urgent and an interpreter is not
available.
The nurse acting as a client advocate should ensure the appropriate use of medical interpreters to
promote adequate client understanding and participation in the decision-making process. This is
particularly important during the informed consent process.
The nurse is caring for a client with chronic pain who just had surgery and is receiving patient-
controlled analgesia (PCA) morphine. The client is in severe pain, with a rating of 10/10, despite
receiving the maximum ordered dose. The nurse calls the health care provider, saying that the
client is still having pain and recommending a higher PCA dose. Which nursing role is being
implemented in this situation?
The role of the nurse as advocate is to protect the rights of the client, including the right to
adequate pain control. The nurse acting as advocate speaks up for clients when they cannot
easily speak for themselves.
(Option 2) In the role of caregiver, the nurse promotes healing and well-being by helping the
client and family set and achieve goals through the nursing process.
(Option 3) In the role of educator, the nurse helps the client and family learn about topics
relevant to their health.
(Option 4) In the role of manager, the nurse coordinates the care of the client among different
members of the interdisciplinary team and across care settings.
An important nursing role is client advocacy, which involves speaking up for clients to protect
their rights and improve their health outcomes and experiences.
There has been a major community disaster. Stable clients need to be discharged to make more
beds available for the victims. Which clients could be discharged safely? Select all that apply.
Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the control
value demonstrates that warfarin has reached a therapeutic level. The long-term antibiotic course
(and follow-up lab work) can continue at home through the PICC line (Options 1, 2, and 5).
(Option 3) Large intestine peristalsis does not return for up to 3-5 days. The client cannot be
discharged until able to tolerate oral intake with normal elimination. The client has to at least be
passing flatus.
(Option 4) Coffee ground emesis indicates upper gastrointestinal bleeding. The etiology and
treatment need to be determined before the client is discharged.
Those who are stable for discharge include the client with multiple sclerosis with ataxia and
diplopia, the client on warfarin (Coumadin) that has reached the therapeutic effect, and the client
with a PICC line for a long-term antibiotic course.
Which situations require that the registered nurse (RN) report to an appropriate authority? Select
all that apply.
The RN is required to report suspected abuse of vulnerable clients (eg, underage, elderly,
mentally ill) to appropriate authorities, regardless of what other practitioners think. A proper
investigation, rather than conflicting opinions, will determine whether abuse has
occurred (Option 3). The RN should report suspected abuse of vulnerable clients even if the
client denies it because other factors (eg, dependence on the abuser, dementia) could be the
reason for denial (Option 4). Sexually transmitted infection (STI) in a child is sexual abuse and
must be reported and investigated (Option 5).
The greater good of society outweighs an individual's right to confidentiality. Gonorrhea is an
STI; the client should be informed that public health will be notified and partners will be
contacted to receive treatment (Option 2).
(Option 1) Cupping is a recognized alternative medicine practice in which a circular object is
typically used to create suction underneath a cup. The tension pulls the skin upward and
promotes release of muscle tension and scar tissue. After the process, the circular marks remain
for a certain period. The location, organized rows, and history help validate the cause of the
marks.
An RN is required to report suspected abuse of vulnerable clients even if other practitioners do
not agree or the clients deny it. An STI in a child is considered sexual abuse and requires
reporting. Reportable conditions by law are not protected from reporting under the
confidentiality of personal health care information in HIPAA.
An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to
be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident
is currently too busy to request that an ICU client be transferred to telemetry so the bed can be
available; the resident will be able to do so in about 6 hours. What action should the ED charge
nurse take first?
It is important to move the client to the ICU and for the ED to continue to care for incoming
clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve
interdepartmental issues when it is necessary for a higher authority to intervene and expedite
processes (Option 2).
(Option 1) The telemetry unit manager would not have the authority to transfer a client.
Although the manager could suggest other transfers, prescriptions for the transfers would still be
necessary. The nursing supervisor can work with the telemetry manager as needed.
(Option 3) The client needs appropriate monitoring equipment and staff, not just a physical
bed. A high-acuity client is not held in a hallway without adequate caregiving support.
(Option 4) The client will be held until a bed and staff are available in the appropriate unit.
However, the charge nurse should at least try to facilitate a timely transfer.
A higher level of authority/chain of command, such as the nursing supervisor, should handle
interdepartmental difficulties.
An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted

with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the
last several months and is "tired of being poked and prodded." Which topic would be most
important for the nurse to discuss with this client's health care team?
This client with advanced chronic obstructive pulmonary disease is approaching the end of life.
The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The
goals of care should be consistent with the client's wishes and emphasize comfort and quality of
life.
Palliative care is appropriate for clients who wish to focus on quality of life and symptom
management rather than life-prolonging treatments (Option 3). Palliative care may eventually
include hospice care, after it is determined that the client has a life expectancy of less than 6
months. The nurse should advocate for the client and collaborate with members of the health
care team to explore care options based on the client's wishes.
(Option 1) This client has not clearly demonstrated a need for skilled nursing; additional
assessment is needed to determine the most appropriate discharge setting.
(Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may
have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It
is not the highest priority in this client, who is nearing the end of life and has expressed an
interest in avoiding further testing and hospitalization.
(Option 4) Physical therapy may be appropriate to help this client maintain current abilities.
However, a client with disease this advanced is not likely to tolerate more activity or gain much
additional functional capacity. Therefore, physical therapy is not the highest priority at this
point.
The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is
often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and
symptom control and may eventually include hospice care based on the client's life expectancy.
A large-scale community disaster occurs and clients must share hospital rooms due to the rapid
influx of new victims. Which room assignments are appropriate in this situation? Select all that
apply.
When clients must be housed together in less than ideal circumstances, those infected with the
same causative pathogens can be placed together. However, a client who is infectious should not
be placed with an immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new
post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly).
Every client in the hospital is on standard precautions; therefore, there should be no concern
about placing a vulnerable post-operative client in the same room where standard precautions are
being taken for another client. In a disaster setting, clients of different age groups can be placed
in the same room together so long as both are stable and noninfectious (even if this is not socially
acceptable).
(Option 1) Though both clients are on contact isolation, they are infected with different
organisms and this places them at risk for cross-infection.
(Option 3) By around age 4, clients with sickle cell disease have some level of
immunosuppression as their spleens are dysfunctional due to infarctions from the sickling
episodes. The spleen then fails to carry out protective phagocytosis, especially to encapsulated
bacteria (eg, streptococcus pneumoniae).
Clients infected with different organisms cannot be placed together in the same room (due to risk
of cross-infection). An infectious client should not be housed with an immunocompromised one.
The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with
pneumonia that morning. Which information is most important for the nurse to communicate
about the client during handoff report?
Current respiratory status is essential to include in handoff report, as it is objective

information related to the client's current condition. Information communicated during report
should allow the oncoming nurse to prioritize care and obtain baseline measurements of the
client's current status and response to treatment. It is especially important to include
information that may not be documented in the medical record. Respiratory status can change
rapidly, and the most current measurements may not be documented, as vital signs are often
documented every 4, 8, or 12 hours (Option 3).
Handoff report typically includes:
 Client's name, location, age, gender, health care provider, and diagnoses
 Client's current baseline measurements, treatment plan, goals, and response to treatment
 Priority and outstanding tasks and changes from previous days
(Option 1) Lung infiltrates and elevated WBC count are expected findings with pneumonia and
are found in the medical record. Diagnostic findings are significant if there is an ongoing trend,
but isolated, expected results are not as helpful in planning care.
(Option 2) Personal opinions are not pertinent to providing care.
(Option 4) The client's IV site is assumed to be patent without complication, or the offgoing
nurse would have changed it. The oncoming nurse should make an individual assessment.
Handoff report should include objective information related to the client's current condition. It is
especially important to include baseline measurements that may not be documented in the
medical record (eg, current respiratory status) so that the oncoming nurse can prioritize care.
After receiving the shift report, the nurse should assess which infant first?
A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24
hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia.
Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions,
lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is
symptomatic and should be assessed first.
(Option 1) A normal respiratory rate for an infant is 30–60/min. This infant is currently stable.
(Option 3) It is normal to auscultate crackles in an infant during the first hour of life. This is
because fluid is still being pushed out of and absorbed by the lungs. This infant is currently
stable.
(Option 4) A normal temperature range for an infant is 97.7–99.7 F (36.5–37.6 C). This infant
is currently stable.
The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring
the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia
and should be treated immediately by feeding or administering a glucose bolus.
The nurse notifies the health care provider of a change in client condition. Which of the
following reports given by the nurse includes the most appropriate and complete information?
The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for

communicating information about a change in client status to the health care provider (HCP). It
includes the following information:
1. S = Situation – what prompted the communication
2. B = Background – pertinent information, relevant history, vital signs
3. A = Assessment – the nurse's assessment of the situation
4. R = Recommendation – request for prescription or action from the HCP
The report given by the nurse in Option 3 contains the most appropriate and complete
information. The nurse includes pertinent data related to history, admission, and present
treatment (background); indicates when and what changes occurred (situation, assessment); and
requests a prescription from the HCP (recommendation).
(Option 1) This report does not include any information indicating a time frame for admission
or when the change in condition occurred.
(Option 2) This report does not include any information related to the admission time frame,
current diagnosis, or pertinent data assessed by the nurse giving the report.
(Option 4) This report does not include any information related to the admission time frame or
pertinent data assessed by the nurse giving the report.
Nurses commonly use the SBAR framework to report changes in client status to the health care
provider, communicating the current situation, client background, nurse's assessment, and a
recommendation for prescription or action.
Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads
a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my
clients." What is the best response by the nurse?
The nurse should be assertive and deal with the issue directly now. The nurse is using an "I"
statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand,
which the UAP can perform. The request should be given as a directive, not as an option.
Putting the request in the scope of a universal goal on which everyone can agree, such as quality
care, makes it harder for the UAP to refuse.
It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts
the requested action.
(Option 1) The request should not be given as an option as there is a legitimate need the UAP
can meet. The nurse needs to be directive and assertive when indicating what needs to be done.
(Option 3) This is an avoidance action and does not resolve the bigger issue. The nurse should
attempt to rectify the issue first rather than focus on discipline. Discipline measures are
appropriate if there is insubordination (the UAP refuses) or a pattern of behavior (on every shift
the UAP does not answer lights despite being told).
(Option 4) The nurse should give the UAP a chance to change behavior first. Speaking to the
manager in the future does not resolve the current issue. The nurse can take this step if there is
insubordination or a pattern of behavior.
The nurse should use assertive communication techniques to deal with a staff member directly
and immediately by telling rather than asking for certain actions. The nurse should not attack the
individual's character or initially make threats (aggression) and should not avoid the issue by just
performing the action itself (avoidance).
A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at
the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by
the nurse?
When there is inter-staff disagreement, it is important to not have a public "show." The first
action should be to take the conflict "off stage." This is especially true when there is a
power/authority difference (eg, HCP/nurse). Rather than suggest and wait, the nurse should
immediately leave and go to a private area. That way the disruptive person has to either follow
the nurse or stop talking because there is no longer an audience. Once in private, the nurse can
acknowledge the HCP's concerns and work to resolve the issue (Option 4).
(Option 1) Confrontation and aggressive response usually do not resolve or diffuse the situation
and will still involve an audience.
(Option 2) The nurse should first take the conversation private as the HCP is not likely to calm
down soon. The nurse can offer a blameless apology (eg, "I'm sorry there has been a problem")
and then focus on the solution. This should occur out of the public eye.
(Option 3) This response involves avoidance rather than working to resolve the situation. It
does not benefit staff or clients to see providers having a public disagreement.
The first response to public displays of disruptive behavior is to take action to make the
conversation private.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary

colostomy. The parents' primary language is Vietnamese and their English proficiency is very
limited. What is the best approach for the nurse to use when instructing the parents on how to
care for the child at home?
Effective teaching can be accomplished only with effective communication, which can be

compromised by language barriers, cultural differences, and low health literacy. When
an interpreter is necessary, using a translator who is skilled in medical terminology is the best
approach to provide accurate information (Option 4). Hearing instructions and information in
one's primary language decreases the risk of adverse clinical consequences.
When a professional medical translator is unavailable, language lines, telephone systems, and
remote video interpreting services can be used. Translation by family members and friends
should only be used as a last resort and only with the permission of the client, especially in
situations where sensitive information needs to be communicated (Option 3). Children should
not be used as translators except in an emergency situation when there are no other options.
(Option 1) This client's parents have very limited English language proficiency; this approach
will not be effective in providing instructions about the child's care at home.
(Option 2) Providing written materials without verbal teaching does not give the client (or the
client's legal guardian) the chance to ask questions, nor does it give the nurse the opportunity to
assess the client's understanding of the given information.
When language is a barrier to effective communication and teaching, the nurse should use a
trained medical interpreter for translation purposes.
The nurse caring for a client in the intensive care unit reports a critical laboratory value of
120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm 3 (300 x 109/L) on admission.
The health care provider says this is normal. The client is receiving heparin injections. Which
nursing action would be the most appropriate?
There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets

>100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets
<40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate
heparin discontinuation.
When in doubt of a clinician's judgment, the nurse should document these objections and report
to the nursing supervisor.
(Options 1, 3, and 4) It is important to first refer up the nursing hierarchy.
The nurse should document and then report objections about a clinician's judgment to the nursing
supervisor.
The nurse is triaging victims at the site of a mass casualty incident. Which victim should be
seen first?
During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest
good for the greatest number of people. Clients are commonly triaged using a color-coded
system and placed into four categories. When prioritizing clients for treatment, emergent needs
should be managed first followed by urgent and nonurgent needs. If no clients are identified as
having emergent needs, clients with urgent needs (eg, open fractures with palpable pulses)
should be treated first (Option 2).
(Options 1 and 3) Clients who are expectant due to the severity of their injuries (eg, severe
neurological trauma, full-thickness burns >60% total body surface area) are the lowest priority
for treatment. However, the nurse should provide palliative care, if possible, while addressing
the needs of others.
(Option 4) Clients with nonurgent needs (eg, minor lacerations) should receive treatment after
emergent and urgent clients.
During mass casualty events, the goal is the greatest good for the greatest number of people.
Clients are triaged rapidly using a color-coded system that ranks them from highest medical
priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).
The health care provider (HCP) remarks that the staff nurse has a great body and that it would be
worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and
finds the remarks offensive. What action should the receiving nurse take initially?
Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is
prohibited. Other behaviors that could be defined as sexual harassment include asking someone
for a date after the other person expressed disinterest or making remarks about a person's gender
or body.
The receiving nurse should first immediately and clearly indicate that the attention is unwanted
and the offending HCP should stop. The offending HCP may have erroneously perceived a
mutual attraction. If that is not effective, additional action should be taken. The American
Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report,
document, and support.
(Option 1) The incident should be reported, especially if the offending HCP does not stop. If
the harasser is the immediate supervisor, the receiving nurse should go up the chain of
command. However, the nurse should first simply tell the offending HCP to stop and see if that
resolves the issue.
(Option 3) The nurse should respond with assertiveness, not avoidance. Ignoring the situation
may imply that the nurse does not mind the HCP's attention.
(Option 4) The receiving nurse should document what occurred and how the nurse responded.
The presence of witnesses should be documented. Documentation should be stored somewhere
other than the workplace. However, the nurse should initially communicate assertively that the
actions are to stop before documenting them.
A nurse who receives unwanted sexual advances in the workplace should first immediately and
clearly indicate that the advances are unwanted and that the offending person should stop.
A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to
assist with field triage. Which client should the nurse prioritize for transport to the hospital?
Disaster triage is based on the principle of providing the greatest good for the greatest
number of people. Clients are triaged rapidly using a color-coded system to categorize them
from highest medical priority (emergent) to lowest (expectant).
The client with flail chest (ie, paradoxical chest movement during respiration) from multiple
fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile
fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at
any time. Therefore, this client would be classified as emergent due to airway compromise,
which requires immediate treatment (Option 4).
(Option 1) Spotting at 8 weeks gestation may indicate complications of pregnancy (eg,
miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital signs, this client would be
classified as nonurgent as the fetus is not at the age of viability and there is no evidence of risk to
the mother's life.
(Option 2) The client with a compound fracture and oozing laceration would be classified as
urgent and require care within 2 hours to prevent life-threatening complications (eg, hemorrhagic
shock).
(Option 3) Absent respirations and fixed pupils indicate severe neurologic damage or death.
Therefore, this client would be classified as expectant.
Clients are triaged rapidly using a color-coded system that categorizes them from highest
medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black
(expectant).
The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that
the client may be neglected. Which information most strongly supports the nurse's suspicion of
child neglect?
Child neglect occurs when a caregiver purposely withholds or does not adequately provide
necessary resources to fulfill the basic needs of a child (eg, adequate nutrition, security,
hygiene). Supervisory neglect, leaving children without adequate guardianship to ensure
safety, is one form of child neglect (Option 4). Children age <12 lack formal operational
reasoning and cannot anticipate safety risks or respond appropriately to emergencies, and should
therefore not be left to supervise other children.
It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The
nurse, or social services, should report the situation to an appropriate government child
protective service and/or law enforcement.
(Option 1) Potential job loss indicates that the parent may be overwhelmed. The nurse should
alert a social worker about the situation at a later time to discuss potential assistance.
(Option 2) Transitioning to the role of a single parent can present mental and financial stressors,
possibly requiring assistance from a social worker. However, this does not require immediate
intervention.
(Option 3) A parent stealing food may warrant calling the police or security, but the children's
safety is a priority requiring immediate action.
Supervisory neglect (eg, leaving a young child to supervise other children) is a type of child
neglect and represents an immediate risk to the safety of younger children. The nurse should
ensure that the children are safe and report the child neglect incident to social services, the
appropriate child protective service, and/or law enforcement.
Piaget's theory of cognitive development
Age
Stage Description Developmental hallmark
(years)
 Experiencing the  Object

<2 Sensorimotor environment via senses permanence
& actions  Stranger anxiety
 Pretend play
 Representing real things  Egocentrism
~2–7 Preoperational
with words & images
 Language
development
 Thinking logically about

concrete events  Conservation
Concrete
~7–11  Grasping concrete  Mathematical
operational
analogies transformation
 Performing arithmetic
 Thinking about
 Abstract logic
Formal hypothetical scenarios
>12  Moral reasoning
operational  Grasping abstract
develops
thoughts
Which client condition is concerning and requires further nursing assessment and
intervention? Select all that apply.
The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is
removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation
factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood
loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension.
Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate
significant blood loss. Therefore, this client needs immediate assessment.
(Option 2) This change in vital signs from preprocedure to postprocedure most likely reflects
decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not
produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it
would compress the spinal cord, causing paralysis in the lower extremities.
(Option 3) This client has a pulse of 62/min (normal 60-100/min), which indicates a therapeutic
effect of metoprolol. The nurse should monitor for bradycardia, which is a common and
expected finding following administration of a beta-adrenergic blocker. Bradycardia would
require nursing intervention only if the client became symptomatic (eg, hypotension, dizziness,
nausea).
(Option 5) A neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a
temporary rise. Vital signs are concerning if they rise when a client is at rest.
Vital sign changes that are early signs of concern for hypovolemic shock are tachypnea,
tachycardia, and agitation; hypotension is a late finding.
The health care provider gives the preoperative nurse a signed consent form and walks away
rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need
surgery?" What is the most appropriate action?
Informed consent requires that the health care provider performing the procedure explain
everything to the client's satisfaction (within reason). Signed consent may be witnessed by the
nurse. If the client does not fully understand informed consent, the nurse must notify the health
care provider or refer up the chain of nursing command. The nurse is not responsible
for verifying that the client understands the procedure and its respective risks.
(Option 1) This would be appropriate if the health care provider refuses to talk to the client.
(Option 2) This is not the nurse's responsibility; this request would have to be relayed up the
chain of nursing command.
(Option 4) This is premature; the incident is isolated and not all facts are known.
Clients may not consent to an invasive procedure without being informed of the clinical
reasoning, consequences, and possible complications.
Which client does the nurse assess first after receiving morning report?

The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs
through a special PCA administration set that is attached to the PCA pump. It is attached to a
running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line
each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter
becomes occluded, the PCA drug can back up into the primary tubing each time a dose is
administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis,
which causes vessel wall injury and can lead to thrombophlebitis (Option 1).
(Option 2) The nurse will perform abdominal and pain assessments and will check the function
and patency of the suction. However, this client was admitted yesterday, is stable, and does not
need to be assessed first.
(Option 3) An irregular heart rhythm is to be expected in a client with atrial fibrillation, and a
heart rate of 94/min is within the normal range (eg, 60-100/min). This client is stable and does
not need to be assessed first.
(Option 4) Incontinence of stool in a client with dementia and C difficile is not uncommon. To
provide for immediate client comfort, the nurse can delegate the task of bathing the client to the
unlicensed assistive personnel. This client does not need to be assessed first.
To prioritize care, the nurse first identifies the type of problem, associated complications, and
desired outcomes. The nurse then decides which client problems and needs are most urgent and
require immediate action and which can be delayed.
The nurse calls the health care provider at midnight and states, "Client X in room 212 had a
colectomy yesterday and is now lethargic. The client currently has a rising pulse at 130/min and
a falling systolic blood pressure at 80 mm Hg. I am concerned that the client is going into
shock." With regard to the SBAR (Situation, Background, Assessment, and
Recommendation/Request) communication technique, what is the most important information
excluded by the nurse?
SBAR has been updated in some facilities to I-SBAR-R (Introduction, Situation, Background,
Assessment, Recommendation/Request, and Read-back). This communication technique is a
framework to provide essential information in an organized fashion. It is recommended by the
Joint Commission and is especially useful when a client's condition is changing rapidly.
In this case, the nurse has omitted the Recommendation/Request of SBAR when communicating
with the health care provider (HCP). Examples of appropriate recommendations include asking
the HCP to see the client, perform a diagnostic test, request a consultation, or prescribe IV fluid
administration.
(Option 1) The "B" in SBAR stands for background or recent history (eg, the surgery in this
case). It is unnecessary to give basic demographic information (eg, age, religion) unless the
information is pertinent to the current situation.
(Option 2) Although temperature and trend could be communicated, the vital signs that the
nurse has reported are concerning enough for the HCP to act. A fever/infection is unlikely in the
first 24 hours after surgery.
(Option 4) The "S" is standard for situation (ie, the current change in the client). The focus of
the conversation is the current change in response to a recent procedure, not the client's past
medical history.
SBAR (or I-SBAR-R [Introduction, Situation, Background, Assessment,
Recommendation/Request, and Read-back]) is used to communicate pertinent information
regarding changes in a client's condition in an organized fashion. The content should include the
situation (why the nurse is calling), background, assessment, and a recommendation/request of
the health care provider.
A nursing unit implements a quality improvement process of written reminders to ameliorate

incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client
goal for this process has been met?
The best indicators of a successful intervention (desired effect achieved) are objective criteria.
This is an objective measurable result that can be correlated with the intervention.
(Option 2) Attending an inservice seminar for staff education is an important and necessary step
for intervention implementation. However, the intervention will be successful only if the
information is applied and the desired outcome achieved.
(Option 3) Reporting the number of written reminders given to respective clients is necessary.
However, this reporting of intervention achievement is subjective as recall can be inaccurate.
Even if it were an accurate recounting, it does not prove that the intervention succeeded. The
appropriate focus should be on client outcomes, not nursing staff behaviors.
(Option 4) Although approval from surgeons provides helpful support for the intervention, an
objective evaluation beyond personal opinions is required.
The effectiveness of an intervention should be determined by objective measurable outcomes
that can be correlated with the intervention. It should not be based only on personal opinion or
staff activities.
A client is being discharged with plans to return home alone. The client cannot get up from a
chair without help and is very unsteady when standing, even with a walker. The nurse expresses
concern, but the primary health care provider is adamant that the client be discharged today.
Which team member would be most appropriate to assist the nurse in advocating for this
client?
The case manager and social worker on the interdisciplinary team have expertise in discharge
planning and health care finance. They can assess the adequacy of the discharge setting and
support systems, arrange for resources at home, or discharge to an alternate setting, such as a
rehabilitation facility. They can also help advocate for safe, effective discharge planning.
(Option 1) The clinical psychologist's role is to assess the client's psychological issues and
assist with counseling and coping strategies.
(Option 2) The occupational therapist promotes development of the client's fine motor skills
and ability to carry out activities of daily living.
(Option 3) Although the role of the physical therapist is to assist the client with mobility issues,
the nurse needs someone who can advocate for this client and assist with appropriate discharge
arrangements to promote safety.
The nurse concerned about client safety at discharge should advocate for the client. Other
interdisciplinary team members, such as the case manager or social worker, should be brought in
to advocate for the client and explore alternate discharge resources or settings.
A community mental health nurse is a member of a mobile crisis team providing services to
victims of a category 4 hurricane. Of these strategies, which would be the priority action for the
team to utilize in reaching those who need mental health services?
Individuals impacted by emergencies such as a natural disaster often experience severe

emotional stress and are in need of mental health services. Clients may experience a wide range
of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and
anxiety. Mental health professionals can provide support, crisis intervention, and promote
resilience in coping with the effects of the disaster. Services may be provided in shelters, food
distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes.
However, finding and reaching potential clients and family members in the aftermath of a
disaster can be challenging because:
 Clients may not know where or how to seek help
 Clients may be afraid or unable to leave their homes
 Telephone services and other lines of communication may be disrupted
 Potential clients may leave their homes and go to shelters or alternate housing
 Transportation may be severely limited
It is essential to coordinate outreach efforts to maximize resources and avoid duplication of
services and/or inefficiency in providing services. The mobile crisis team's priority action is to
check in with the local command center, then to assist in planning outreach strategies with other
community agencies, and receive assignments.
(Option 1) Contacting other social service agencies may be part of an effort to coordinate
services once the team has reported in to the local command center.
(Option 2) This is an appropriate outreach strategy after the mobile crisis team has checked in at
the local command center and has received the assignments.
(Option 3) Putting up flyers may not be a particularly effective way to provide outreach to those
affected by a disaster as clients may be afraid to leave their homes or they may be unable to get
to where the services are being provided.
Individuals impacted by natural disasters or emergencies are often in need of mental health
services for assistance in coping with a wide range of reactions and emotions including fear,
confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to
be centrally coordinated by the various community agencies providing services in order to
maximize efficiency and avoid duplicative efforts.
The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a
bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause
the nurse to intervene?
Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in
hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by
applying graduated compression. When fitted properly and worn consistently, the stockings
decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in
any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.
(Option 1) Anti-embolism stockings should be applied before ambulating while the client is in
bed; this maximizes the compression effects of the stockings and promotes venous return. The
UAP has performed this correctly.
(Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has
performed this correctly.
(Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The
UAP has performed this correctly.
Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the
nurse verifies the stockings are correctly fitted and worn appropriately. Incorrect size and fit or
alterations to the stockings can impede venous return.
The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and
pulseless. The nurse calls the health care provider (HCP) at 2 AM, and the HCP begins to yell at
the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is
the best response by the nurse?
The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe
environment for clients. In response to unprofessional conduct, the nurse should shift the
focus of the conversation back to the client's needs, especially in situations that may result in
client injury (Option 1).
(Option 2) Discussing facility policies does not direct the conversation to the client's needs and
fails to address the urgency of the situation. The priority is for the nurse to advocate for the
client's needs because the client is experiencing a serious, limb-threatening, postsurgical
complication.
(Option 3) Confrontational statements are more likely to provoke a fight than result in
appropriate intervention for the client.
(Option 4) Incidents of bullying and workplace violence should be reported to a nursing
supervisor, but the priority is to ensure that the client's needs are addressed.
In response to unprofessional conduct, the priority is to shift the focus of the conversation back
to the client's needs. After the client's needs are met, the nurse can take measures to address the
unprofessional behavior (eg, filing a report).
The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of
the following statements by the nurse are appropriate to include in the report? Select all that
apply.
A handoff of care report is the critical communication that occurs when transferring client care
to another nurse (eg, shift change, department transfer). Transitions of care
require thorough, precise communication to ensure client wellness and safety. Appropriate
handoff communication allows for continuity of care and provides a synopsis of client needs and
details of the client's care.
To ensure appropriate and effective handoff communication, the nurse should:
 Provide identifying information (eg, client's name and room number).
 Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication
infusion bag, need to perform delayed wound care and cause of delay) (Option 1).
 Provide exact, pertinent information (eg, medication dose, time, measurable
outcomes) (Option 3).
 Include multidisciplinary plans (eg, radiology examinations, family meetings, physical
therapy) (Option 5).
 Relay significant client changes in a clear manner (ie, assessment, interventions,
outcomes, evaluation).
(Option 2) Report statements should include exact information (ie, time medication is
administered, measurable outcome using a pain scale). "Good relief" is a vague term.
(Option 4) Handoff should not include biased information or personal opinions (eg, "rude") and
should include visitor information only if the visitor is involved in client care and/or teaching. It
is appropriate to include information about a client's medication list.
Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care
priorities and upcoming or outstanding tasks; exact, pertinent information; multidisciplinary
plans; and significant client changes.
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting
fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client
should the nurse care for first?
Disaster triage is based on the principle of providing the greatest good for the greatest number
of people. Clients are triaged rapidly using a color-coded system to categorize them from
highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high-
pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked
upper airways, is at risk for impending respiratory failure due to a compromised airway. This
client should be classified as emergent, requiring immediate treatment and possibly prophylactic
intubation (Option 4).
(Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs
are suspected to have at least 72% total body surface area burns and should be classified as
expectant (black tag).
(Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but
can be easily self-managed by provision of warm, dry blankets; this client should be classified as
nonurgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism,
dysrhythmias, and coagulopathies.
(Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop
hyperglycemia, which is unlikely to cause rapid deterioration. This client can perform self-care
and should be classified as nonurgent (green tag).
Clients are triaged rapidly using a color-coded system that categorizes them from highest
medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black
(expectant).

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The nurse on the neurotrauma unit receives report on 4 clients.

Which client should the nurse

Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing

Glasgow Coma Scale

4 - Spontaneous (open with blinking at baseline)

(C - Not assessable [eg, trauma, edema])

4 - Confused (converses but confused, disoriented)

3 - Inappropriate (inappropriate words)

(T - Not assessable [intubated])

4 - Withdraws from pain

2 - Extension in response to pain (decerebrate posturing)

 Use best response for each category (range = 3-15).

Leukemia is characterized by unrestricted proliferation of abnormal white blood cells

Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements)

Anticipatory guidance prepares clients and caregivers for future health needs and is useful

Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg,

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which

Surgical debridement of an unstageable pressure injury involves using a scalpel

Unstageable pressure injury

 Neisseria meningitidis  Surgical mask

A unit quality improvement committee assesses process standards (guidelines, systems, and

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted

Current respiratory status is essential to include in handoff report, as it is objective

The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary

Effective teaching can be accomplished only with effective communication, which can be

There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets

 Experiencing the  Object

 Thinking logically about

Which client does the nurse assess first after receiving morning report?

A nursing unit implements a quality improvement process of written reminders to ameliorate

Individuals impacted by emergencies such as a natural disaster often experience severe

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