1. The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should

PREBOARD 19

1.) 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?

• Room 1 – client in skeletal traction following a fracture of the femur, who has erythema at the pin sites
• Room 2 – client with cellulitis and osteomyelitis following blunt trauma of the tibia
• Room 3 – client with compartment syndrome following a crush injury, who is 1 day post fasciotomy
• Room 4 – client with a long leg cast following open reduction of a fractured tibia

2.) 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?

• The parent cannot stay at the hospital due to potential job loss from absence
• The parent is in the process of a divorce and will soon be a single parent
• The parent is witnessed stealing food and drinks from the cafeteria
• The parent leaves the client’s younger sibling to care for the client’s newborn sibling

3.) 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?

• Basic demographic information
• Current temperature and trend
• Requesting action by the health care provider
• Significant past medical history and allergies

4.) The health care provider (HCP) repeatedly makes unwanted sexual advances toward the nurse. Which of the following actions by the nurse are appropriate? Select all that apply.

• Complete an incident report for each occurrence
• Consult the facility’s sexual harassment policies
• Report the behavior to the supervisor immediately
• Seek support from a licensed professional counsellor
• Tell the HCP to stop the comments

5.) 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?

• Client with charred, leathery skin over entire back, chest, and legs
• Client with cool skin, shivering from sitting in water until rescued
• Client with diabetes who was unable to take prescribed insulin today
• Client with high-pitched, crowing inspiratory respirations

6.) 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?

• Decreased length of hospital stay
• Less obvious needs of clients met accordingly
• Properly educated clients
• Reduced number of medical errors

7.) 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.

• Acute head injury with Glasgow Coma Scale of 12
• Admitted with cirrhosis of liver with oozing esophageal varices
• Asthma exacerbation with peak flow at 85% of personal best
• Deep venous thrombosis on IV heparin with platelets 40,000/mm

3 (40 x 10 9 /L)

• Myasthenia gravis with ptosis in the evening

8.) After receiving the shift report, the nurse should assess which infant first?

• An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min
• An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L)
• An infant with bilateral crackles who was delivered vaginally 30 minutes ago
• An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)

9.) The health care provider gives the preoperative nurse a signed consent form and walks away. The client turns to the nurse and states, “I don’t know what’s going on. Why do I need surgery?” what action should the nurse perform first?

• Document the client’s statement in the electronic medical record
• Inform the nursing supervisor that the client needs additional teaching
• Notify the operating room scheduler of a possible delay in surgery
• Request that the health care provider clarify the client’s concerns

10.) Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

• Assess for copious secretions to determine exposure
• Assist the victims farthest from the source first
• Assist the victims with the most severe symptoms first
• Monitor for diplopia to determine extent of exposure

11.) 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?

• Act as a witness for the informed consent process
• Provide additional information about what the client can expect
• Report the surgeon to the ethics board for using an inappropriate consent process
• Talk to the surgeon privately about using a trained Spanish-language medical interpreter

12.) 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?

• Call the telemetry unit manager
• Notify the nursing supervisor
• Send the client to ICU to “hold” the client in the hallway
• Wait until the resident has time to request the transfer

13.) 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?

• Call the answering service and speak to the health care provider now
• Document the results of the culture in the client’s medical record
• . Leave a message on the health care provider’s office phone
• Speak to the health care provider on rounds in the morning

14.) 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?

• 52-year-old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels
• 60-year-old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of

diltiazem

• 65-year-old admitted last night for third-degree heart block who is awaiting permanent pacemaker

placement

• 78-year-old with end-stage heart failure and ejection fraction of 15% whose family is requesting

palliative care

15.) After talking to the client, the health care provider (HCP) tells the registered nurse that the client’s signature is needed on the consent from 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?

• Call the HCP to come and talk to the client
• Refuse to witness the signature on the consent
• Teach the client about a low-fat diet
• Tell the client that the HCP will explain it later

16.) 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?

• Assign the graduate nurses to a unit without cultural diversity until cultural competency is achieved
• Provide the graduate nurses with a workshop designed to teach about cultures encountered at work
• Request that the charge nurse assign the graduate nurses 2 culturally diverse clients each shift
• Suggest that the graduate nurses research various cultures and provide an in-service to the staff

17.) 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.

• 1 UAP repositioning a client who is 8 hours postoperative total hip replacement
• 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair
• 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours
• 2 UAPs using the log-rolling technique to move a client with a cervical collar
• 3 UAPs using a draw sheet to move a client who weighs 220 lb (100 kg) up in bed

18.) Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply.

• Client has a row of 3-inch circles down the back from “cupping”
• Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability

and Accountability Act (HIPAA)

• RN thinks a teenage client’s signs are from abuse, but the health care provider does not
• RN thinks an elderly client’s signs are from abuse but the client denies this
• Syphilis is diagnosed in an 11-year-old who denies sexual activity

19.) 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?

• Did the study have institutional review board approval?
• Do the characteristics of the sample population match those of the nurse’s unit?
• What are the credentials of the study’s researcher?
• What was the financial support provided for the study?

20.) 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?

• Need for discharge to a skilled nursing facility
• Nutritional consult with instructions on a high-calorie diet
• Option of palliative care
• Physical therapy prescription to promote activity

21.) 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.

• Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line
• History of multiple sclerosis with ataxia and diplopia
• One day postoperative from a hemicolectomy
• Reporting abdominal pain with coffee ground emesis
• Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value