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1. A nurse is caring for a client who has a facial injury. The client tells the nurse that the injury was a result of partner violence. After treating the client's physical injury. Which of the following actions should the nurse take next? Provide coping strategies. Refer the client for counseling services. Assist the client to develop a safety plan. Take photos of the client's injuries. Ans Answer Ans Take photos of the client's injuries. Rationale Ans The first action the nurse should take using the nursing process is to collect data from the client by documenting and taking photos of the client's injuries. Accurate documentation of the client's injuries in the medical record can provide valuable evidence in the event future legal action is taken against the perpetrator. 2. Anurse is caring for a client who has pancreatic cancer. The client tells the nurse that they do not want the chemotherapy the provider recommended. Which of the 1/39 following responses should the nurse make? "You should discuss your treatment with your loved ones before making a decision." "You have the right to refuse chemotherapy, but you should understand the risks." "The side effects of chemotherapy are not as bad as they used to be and can be managed." "Your health will continue to decline if you don't receive chemotherapy." Ans An- swer Ans "You have the right to refuse chemotherapy, but you should understand the risks." Rationale AnsThe nurse should recognize the client's right to refuse treatment and notify the provider to discuss the risks of refusing treatment with the client. 3. Anurse is discussing advantages of using the nursing clinical information system (NCIS) with a newly licensed nurse. Which of the following advantages should the nurse include? Select all that apply. Eliminates potential legal risk Gives an overview of the cost of treatment Reduces errors of omission Enhances ability to track medical records Provides immediate access to members of the interprofessional team Ans Correct Answers AnsWhen giving change-of-shift report, the nurse should include any changes in the treatment plan, such as switching the client from parenteral to oral pain medication. 5. A nurse in a long-term care facility is caring for a client who has dementia and is refusing to take an oral medication the provider prescribed. Which of the following actions should the nurse take? Ans Answer Ans Attempt to administer the medication later in the shift. Rationale Ans Clients who have dementia lack short-term memory. If the client previ- ously took this medication without difficulty, a strategy that might work is to attempt to administer the medication to the client a short while later. The client might not remember the previous incident and take the oral medication. 6. A nurse on a pediatric unit is assisting with the care for a group of clients. From which of the following clients should the nurse collect additional data first? Ans Answer AnsA child who had a tonsillectomy 12 hrs ago and is frequently clearing her throat. Rationale Ans A child who had a tonsillectomy 12 hrs ago and is clearing their throat or swallowing frequently is unstable; therefore, this client is the highest priority. Frequent clearing of the throat or swallowing is an indication of postoperative hemorrhage, which requires immediate care. The nurse should collect additional data from this client first before notifying the provider. 7. A nurse is assisting with the transfer of a client who had a C7 spinal cord injury toa rehabilitation unit. Which of the following findings should the nurse identify as the priority to include in the transfer report? Autonomic dysreflexia Reddened coccyx Current vital signs Hypertension history Ans Answer Ans Autonomic dysreflexia Rationale Ans The greatest risk to the client is injury from autonomic dysreflexia due to the risk for hypertensive cerebrovascular accident and seizures. This is the priority finding for the nurse to include in the transfer report. Answer Ans "| cannot allow you access to her medical record unless your mother gives her consent." Rationale Ans The nurse should not release private health information without the client's consent, as this is a violation of client confidentiality. 11. Anurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse attend to first? Ans Answer Ans A client who is taking digoxin and has a digoxin level of 2.6 ng/mL. Rationale Ans A client who is taking digoxin and has a digoxin level of 2.6 ng/mL is unstable because of the risk for life-threatening dysrhythmias; therefore, the nurse should attend to this client first. The expected reference range for digoxin is 0.8 to 2.0 ng/mL. Digoxin toxicity begins at 2.4 ng/mL and can cause nausea, vomiting, diarrhea, and visual disturbances. 12. The partner of a client who has been receiving dialysis tells the nurse that the client has stated a desire to end treatment.The client's partner is upset and asks the nurse for help. Which of the following responses should the nurse make? Ans Answer Ans "You seem upset. Tell me more about their reasons for making this decision." Rationale Ans This is a therapeutic response that demonstrates that the nurse recog- nizes the 7/139 partner's feelings and respects the client's autonomy. 13. A home health nurse is visiting a client who has a new diagnosis of Parkinson's disease. Which of the following findings should the nurse plan to address first? Ans Answer Ans The client's medications are missing. Rationale Ans The greatest risk to this client is injury from interruption in the client's medication regimen. Abrupt withdrawal from some medications can cause severe adverse effects. Therefore, the priority finding for the nurse to address is the client's missing medications. 14. A nurse is caring for a client who is scheduled for an arthroplasty. The client states, "IL changed my mind. | don't want the surgery now." Which of the following responses should the nurse make? Ans Answer Ans "| will let your surgeon know that you have decided to cancel." Rationale Ans The nurse should respect the client's right to refuse treatment. It is the responsibility of the nurse to notify the surgeon that the client has changed their mind about the surgery. from the AP to determine their level of knowledge of the task. 18. A nurse working on a medical-surgical unit has concerns about ongoing staffing shortages that compromise client safety and delivery of care. Which of the following actions should the nurse take? Ans Answer Ans Notify the nursing supervisor. Rationale Ans It is the responsibility of the nurse to report situations that create the potential for unsafe practice, such as staffing shortage, to the nursing supervisor. 19. A nurse is caring for a client who has just received a diagnosis of stage | lung cancer. The client tells the nurse that she is unsure about sharing the information with her brother. Which of the following responses should the nurse make? Ans Answer Ans "You can choose to keep your health care information private." Rationale Ans It is the nurse's responsibility to inform the client of their rights, including their right to confidentiality. A client's health care information should not be shared with others without the client's consent. 20. A nurse is assisting with completing a transfer report for a client who sustained spinal cord injuries and is moving to a long-term care facility 10/39 for rehabilitative care. Which of the following information should the nurse include? Ans Answer Ans List of continuing treatments. Rationale Ans The nurse should provide the receiving nurse and facility with pertinent client information to facilitate continuity of care. A list of the client's continuing treatments should be provided in the transfer report in order to maintain care and address the client's current needs. 21. A nurse is assisting with planning an in-service regarding client advocacy. The nurse should recommend which of the following topics be included in the in-service? Select all that apply. Ans Correct Answers Nurse advocates support clients with making health care decisions. A nurse advo- cate protects the rights of clients. The nurse should support the client with making health care decisions, which promotes autonomy. Nurse advocates promote clients' access to health care. A nurse advocate protects the rights of clients. The nurse should ensure that all clients have access to health care. Nurse advocates mediate conflicts between clients and other staff regarding treat- ment. A nurse advocate protects the rights of clients. The nurse should mediate conflicts between clients and other staff regarding treatment to ensure that clients receive care to meet their 11/39 23. Anurse enters a client's room and overhears the assistive personnel (AP) talking with the client about the condition of the client in the room next door. Which of the following actions should the nurse take? Report the incident to the charge nurse. Clarify with the client what information the AP discussed. Confront the AP in front of the client about violating client confidentiality. Close the door to the client's room so the client next door does not hear the discussion. Ans Answer Ans Report the incident to the charge nurse. Rationale Ans According to the Health Insurance Portability and Accountability Act (HIPAA), the nurse has a legal obligation to protect the disclosure of client's personal information. The AP is breaching the other client's confidential information. The nurse should report the incident to the lowest person in the facility hierarchy that is responsible for addressing the situation. Therefore, the nurse should report this information to the charge nurse to ensure client safety. 24. Anewly hired nurse is having conflict with another nurse who consistently demonstrates bullying behavior. Including excessive demands. Which of the following strategies should the newly hired nurse use to help de-escalate the situation? Inform the nurse that the behavior is unacceptable. Challenge the nurse about their demands. Compliment the nurse about the quality of care they provide. 13/39 Request a transfer to a different nursing unit. Ans Answer Ans Inform the nurse that the behavior is unacceptable. Rationale Ans By informing the nurse that there is zero tolerance for bullying behavior, the newly licensed nurse is making it clear that there will be consequences if the bullying behavior continues. If it does, the newly hired nurse should report the behavior to the manager and send a written complaint to the facility's human resource department. 25. A nurse is assisting with the plan of care for a group of clients. Which of the following actions by the nurse demonstrates an effective use of time management skills? Beginning with the client's least important tasks first Starting a client procedure and gather supplies as needed Documenting interventions at the end of the shift 14/39 Instruct a client about postoperative breathing. Change a dressing on an invasive line for a client. Insert an indwelling urinary catheter for an incontinent client. Obtain a scheduled blood glucose reading for a client who is stable. Ans Answer Ans Obtain a scheduled blood glucose reading for a client who is stable. Rationale Ans The nurse should assign the AP to obtain a scheduled blood glucose reading ona stable client. This task is within the range of function for an AP. However, if a client's condition is unstable, a licensed nurse should obtain the client's blood glucose reading. 28. A nurse is reviewing incident reporting with a newly licensed nurse. For which of the following situations should the nurse plan to complete an incident report? Anurse changed a client's medication schedule due to medication incompat- ibility. A nurse left a client's IV tubing for a continuous infusion in place for 36 hrs. A visitor closed the restroom door on his hand. A family member yelled at a client and threatened never to see her again. 16/39 Answer Ans A visitor closed the restroom door on his hand. Rationale Ans The nurse should complete an incident report when anyone within the facility sustains an injury, including visitors. 29. A nurse is reinforcing discharge teaching with a client who is recovering from a stroke and has hemiparesis along with dysphagia. Which of the follow- ing instructions should the nurse include in the teaching? Include crackers with peanut butter as a snack. Rest for 15 min prior to mealtimes. Place food in the stronger side of mouth. Extend the neck when swallowing foods. Ans Answer Ans Place food in the stronger side of mouth. Rationale Ans The nurse should instruct the client to place food in the unaffected side of their mouth. This aids in the chewing and swallowing of food and reduces the risk for aspiration. 30. A nurse is reinforcing discharge teaching with a client following a vasecto- my. Which of the following statements by the client indicates an understanding of the teaching? Ans Answer Ans "| should use ice packs to decrease swelling." 17/39 Limit visitors' exposure to the client to 1 hr per day. Check the client's linens for evidence of a dislodged implant. Remove the client's linens from the room at the end of each shift. Ensure that visitors keep a distance of at least 1 m (3.3 feet) from the client. Ans Answer Ans Check the client's linens for evidence of a dislodged implant. Rationale Ans The nurse should plan to check the client's linens for evidence of a dislodged implant to ensure the client's continuous treatment and reduce the risk of exposure to radiation. 33. A nurse is contributing to the plan of care for a client who has heart failure. The client has been instructed to limit their sodium and fluid intake. Which of the following referrals should the nurse suggest? Social worker Occupational therapist Dietitian Physical therapist Ans Answer Ans Dietitian. Rationale AnsThe nurse should suggest a referral for a dietitian who is specialized to consult the client about low-sodium food selections and fluid restrictions. 34. A charge nurse is reinforcing teaching with a newly licensed nurse about maintaining client's confidentiality. Which of the following statements should the charge nurse 19/39 include? "You should place a client's vital signs on the white board in the client's room." "You may discuss information about a client's care with family members." "You may share an assigned password to access clients' records on the computer with another nurse." "You should encrypt client health information when sending e-mails." Ans An- swer Ans "You should encrypt client health information when sending e-mails." Rationale AnsThe nurse should encrypt client health information when sending e-mails to protect client confidentiality. 35. Anurse is preparing to administer a breathing treatment to a client who has COPD. The client states, "| don't want to have this done. | don't like it blowing in my face." Which of the following responses should the nurse give? "L will come back later when you are not upset." 20/39 
