PN_Management_Online_Practice_2017_A

PN Management Online Practice 2017 A: A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facilit ...

PN Management Online Practice 2017 A: A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility? The client develops command hallucinations  Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility. A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance? The client has a circular area of nonblanchable redness on her left heel  A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on her left heel as a variance because this indicates the initial stage of a pressure ulcer and is not an expected outcome. A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take?  Select an interpreter who is the same gender as the client. Ensure interpreters provided by the facility have knowledge of medical terminology. Choose an interpreter from the same ethnic background as the client. A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take? Encourage each staff nurse to give up something as part of the negotiation.  The charge nurse should encourage each staff nurse to give up something as part of the negotiation so that a compromise can be reached that is a win-win situation for each party. A nurse overhears two assistive personnel discussing the details of a clients diagnosis and treatment plan int the hospital cafeteria. Which of the following actions should the nurse take? Inform the APs that the conversation violates the client’s confidentiality  The nurse should intervene immediately to stop the conversation and protect the client by informing the APs that the conversation violates the client's confidentiality. A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions demonstrates the nurses role as client advocate?  The nurse assists a client in communication end of life decisions to the provider The nurse acts in the role of client advocate when protecting the client's legal and ethical rights. A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation?  A treatment that was refused by the client. The nurse should document treatments that were omitted due to client refusal in the medical record. A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of the following manifestations should the nurse include?  Headaches The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning. A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Which of the following actions should the nurse take first?  Check the client for injuries. When using the nursing process, the nurse should identify that the priority action is to collect data from the client. Therefore, the first action the nurse should take is to check the client for injury. A charge nurse is a member of the resource management team for a skilled care facility. Which of the following actions should the charge nurse implement to ensure the facility is providing cost-effective wound care for clients?  Develop a spreadsheet to prepare a budget for wound care supplies The nurse should use a spreadsheet to manage numerical data for the preparation of a budget. The use of a spreadsheet allows the nurse to analyze this data to ensure that cost-effective care is provided to clients. A nurse is reinforcing discharge teaching with a client who is 2 days postpartum. The client expresses concern about a lack of family support and limited financial resources. Which of the following responses should the nurse make?  "How do you feel about discussing your concerns with a social worker?" This is a therapeutic response by the nurse because it addresses the client's concerns and ultimately provides the client with resources to help meet her specific needs. The social worker can connect the client with supportive community resources. A nurse is assisting with the discharge of a client who has a new permanent colostomy. the client expresses concern about learning to care for the appliance and obtaining supplies discretely. Which of the following actions should the nurse take?  Suggest that the client join ostomy support group. Arrange a follow-up appointment with an enterostomal therapy nurse. Provide the client with the name and number of an ostomy supply delivery service. Request a social work referral for the client to discuss financial concerns A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator?  The facility-wide fall injury rate for the previous quarter is 3% This is a valid outcome indicator because it provides statistical evidence related to quality of care. A nurse is assisting with the care of a client who has terminal cancer and is receiving chemotherapy. the client tells the nurse that she is only continuing treatment for her familys sake. Which of the following responses should the nurse make?  "Lets talk about your reasons for continuing treatment" This response by the nurse is therapeutic because it focuses the conversation on the key components of the message and allows the client to discuss the treatment and any concerns she is having. The nurse also validates the client's feelings and thoughts, which enhances trust between the nurse and the client. A nurse is contributing to the plan of care for a client who has a prescription for a 24 hour urine specimen. Which of the following interventions should the nurse plan to include?  Begin the timed collection by discarding the first specimen Post the times for urine collection above the toilet in the clients bathroom Obtain a clean specimen collection container for use during the test A nurse is preparing to delegate assignments after receiving change of shift report. Which of the following tasks should the nurse assign to an assistive personnel (AP)?  Provide postmortem care The nurse should assign the AP to provide postmortem care because this task is within the AP's range of function. A nurse is contributing to the plan of care for a client who has acute hypothyroidism. Which of the following interventions should the nurse include in the plan?  Provide the client with a reduced-calorie diet The nurse should provide the client who has hypothyroidism with a reduced-calorie diet. Hypothyroidism causes the client's metabolism to decrease, which can result in weight gain. A reduced-calorie diet will help the client keep weight gain to a minimum and contribute to weight loss. A nurse arrives for her shift and is assigned mo