Safe and Effective Care Environment

A nurse is developing a discharge plan for a client with advanced heart failure. The client requires home oxygen therapy equipment, needs to learn energy conservation techniques for bathing, and requires initial education on a strict low-sodium diet. The client expresses anxiety about managing these changes at home. Which collaborative actions should the nurse include in the plan of care? (Select all that apply.)

An older adult client with severe chronic obstructive pulmonary disease (COPD) is admitted for acute hypercapnic respiratory failure and requires continuous bilevel positive airway pressure (BiPAP). The client becomes intensely agitated, repeatedly attempting to remove the BiPAP mask and grasp at an indwelling arterial line. The healthcare provider prescribes bilateral soft wrist restraints and PRN intravenous lorazepam for severe agitation. Which intervention should the nurse implement to best maintain client safety?

A client is admitted to the inpatient medical unit with severe abdominal cramping and frequent watery stools. Laboratory results confirm an active Clostridioides difficile (C. diff) infection. Which of the following infection control measures should the nurse implement? Select all that apply.

An interdisciplinary team is conducting rounds on a medical-surgical unit housing clients with various infectious diseases. Which of the following observed practices indicate correct adherence to transmission-based precautions? Select all that apply.

The registered nurse (RN) is managing care delivery on an acute neurovascular step-down unit. Which task assignment demonstrates adherence to the principles of safe delegation?

A registered nurse (RN) on a neurology step-down unit is assigning tasks for the upcoming shift. The nursing team includes the RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the RN to delegate? Select all that apply.

A registered nurse (RN) enters a preoperative staging area to witness the surgical consent signature for a 65-year-old client scheduled for a pacemaker insertion. The client's spouse and an unlicensed assistive personnel (UAP) are present. The RN notes the client is acutely lethargic and disoriented, which the spouse reports began shortly after the client received a preoperative dose of intravenous midazolam. The surgeon is waiting to proceed and requests the RN to witness the signature immediately so the surgical schedule is not delayed. Which actions by the RN are appropriate in this situation? (Select all that apply.)

A registered nurse on a medical-surgical unit receives the morning handoff report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).

A client is preparing for discharge following a 4-week hospitalization for severe Guillain-Barré syndrome. While the client's respiratory function is now stable, they exhibit significant residual weakness in their intrinsic hand muscles, preventing them from grasping eating utensils or manipulating buttons on clothing. The client's spouse expresses feeling overwhelmed about managing these daily care tasks at home and states, 'I do not know how we will afford all the special tools the doctor said we might need.' Which interdisciplinary collaboration action by the nurse is the most appropriate?

A registered nurse (RN) and an unlicensed assistive personnel (UAP) are working together on a nephrology unit. Which of the following client care activities is most appropriate for the RN to delegate to the UAP?

A client with newly diagnosed severe coronary artery disease is scheduled for a coronary artery bypass graft. The nurse brings the informed consent document to the client's room for a signature. The client states, "The doctor said I need this surgery, but I do not really understand what the alternative treatments are or what will happen if I refuse it. I will sign it anyway because I want to get better." Which of the following is the most appropriate action by the nurse?

A 45-year-old client is admitted to the emergency department with a ruptured appendix and requires urgent surgery. Thirty minutes ago, the client received 2 mg of intravenous hydromorphone for severe pain. The surgeon explains the procedure, risks, and alternatives to the client and their spouse, who is the client's legally designated healthcare proxy. The client is lethargic but accurately repeats the surgical information and states, "I understand the risks. I want the surgery. Give me the pen to sign." Which action by the nurse is legally and ethically required?

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

A nurse is receiving the morning shift report for a group of clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

A nurse in the emergency department is assessing a 4-year-old child and observes multiple circular, healing burns on the child's back that resemble cigarette burns. The parent states the child accidentally bumped into a hot radiator. Which of the following is the priority legally required nursing action?

A client is rushed into the trauma bay with severe respiratory distress, absent breath sounds on the right side, and a tracheal shift to the left. The client's blood pressure is 76/40 mm Hg and oxygen saturation is 81% on high-flow oxygen. The client is increasingly lethargic and unable to verbally respond. The attending physician prepares for an immediate tube thoracostomy and instructs the nurse to "get the consent form signed quickly" before the incision is made. Which is the most appropriate action by the nurse?

Upon receiving the handoff report on a cardiovascular step-down unit, the nurse is planning the initial client rounds. Which client requires the nurse's immediate assessment?

Following the morning shift report on a maternal-newborn unit, the registered nurse prepares to round on four assigned clients. Which client must the nurse assess first?

A nurse is preparing to telephone the healthcare provider to report a client's abnormal laboratory result. Arrange the nurse's planned statements in the correct sequence using the SBAR (Situation, Background, Assessment, Recommendation) communication tool. (Place the first statement at the top and the last statement at the bottom.)

A nurse is caring for a young adult client who was voluntarily admitted to an inpatient psychiatric unit three days ago with severe major depressive disorder. This morning, the client suddenly appears remarkably peaceful, gives their favorite watch to a peer, and states, 'Everything makes sense now. I am leaving this hospital today.' The client demands their personal belongings and attempts to exit the locked unit. Which of the following actions are legally and ethically required by the nurse? Select all that apply.