South University - FCCA 274 C / FCCA 274 C Exam LATEST AND GRADED A+

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FCCA 274 C Exam 1. A patient recovering from a motor vehicle accident is scheduled for transfer to an extended care facility. The patient states to the RN “I’m a little bit nervous about this tran... sfer.” Which intervention by the RN will foster a smooth transition to the next level of care? Explore the option of family accompanying the patient during transport. Inform the patient that anxiety about a new facility is normal and everything will be fine. Encourage the patient to perform relaxation techniques taught by the social worker. Collaborate with the health care provider about an anti-anxiety medication for the patient. 2. The RN contacts the health care provider to report a change in a patient’s condition. Which is an appropriate introduction to the patient report by the RN? “I am calling because Mr. Smith in room 21 doesn’t look good.” “This is Ann the nurse caring for Mr. Smith. Sorry to bother you.” “I am the RN caring for Mr. Smith whose condition has deteriorated.” “This is Ann Jones, RN at ECHO Hospital, calling about Mr. Smith.” 3. During interdisciplinary rounds, a patient reports frequent nightmares that is interfering with restorative rest. What would be an appropriate short term goal agreed to by the patient and the team? The patient will resume regular activities of daily living. The patient will have no “flashbacks” or disturbing thoughts. The patient will be able to discuss the event without feeling anxious. The patient will be able to sleep without medication. 4. A patient has chronic myalgia related to Lyme disease. Which members of the team would contribute to the patient’s plan of care? Select all that apply. Registered Nurse Physical therapist Respiratory Therapist Infectious disease physician Clinical Pharmacist 5. The Unlicensed Assistive Personnel (UAP) reports to the RN “Mr. Jones seems different, a little vague and slightly confused.” What is the appropriate response by the RN? “I did not notice any changes, but I will do a more in-depth assessment.” “I am busy with another patient. Can you keep an eye on Mr. Jones?” “Many elderly people get confused when in the hospital.” “There were no changes in his vital signs from baseline an hour ago.” 6. An RN caring for a pregnant woman in labor states to the obstetrician “The fetal heart rate is 80 beats per minute.” The obstetrician replies “Yes, thanks.” What is an appropriate initial response by the RN? “The fetal heart rate is 80.” “I will continue to monitor and report the findings.” “We need to notify the surgical team now.” “The baby seems to be in distress.” 7. The RN manager is coordinating the implementation of patient centered rounds for the nursing unit. Which action facilitates quality, cost-effective use of the team members’ time during patient-centered rounds? Encourage physician orders be entered once rounds are completed. Have a standardized system when conducting patient rounds. Delay visiting hours until after daily rounds are complete. Incorporate teaching of various disease states during rounds. 8. The healthcare provider requests the RN’s presence when delivering “bad news” about a patient’s condition to a family member. The family member immediately begins to voice expletives and punches the wall. What is the most appropriate action by the RN? Initiate the institution’s safety protocol. State the behavior is not helping the patient. Offer to contact spiritual care for the family. Reassure the family member everything will work out. 9. The RN is caring for a client who is having a bedside procedure. The health care provider verbally tells the RN: “Give 4 mg of morphine sulfate intravenously to the client now.” Based on TEAMSTEPPS, what is the RN response? “Do you want the client to receive morphine now?” “The medication was administered as ordered.” “Are you sure you want that amount of morphine to be given?” “4 mg of morphine sulfate intravenously to be given now.” 10. Which outcome evaluates the effectiveness of the interprofessional team’s plan to empower a patient with heart failure to manage this personal illness? The patient verbalizes methods to identify and manage stress. The patient is discharged home within the expected length of time. The patient reports overall satisfaction with health care providers. The patient contacts primary provider with early signs of a potential problem. 11. During interprofessional rounds, one team member consistently interrupts other members of the team. What is the appropriate action by the RN to resolve the issue? Privately speak with that person to convey the impact of the behavior. Suggest the nurse manager attend rounds to help address the behavior. Encourage team members to provide essential information when asked. Tell that member to stop interrupting and listen to all team members. 12. When an RN enters a patient room to perform a dressing change, the case manager is discussing discharge plans with the patient. What is the most appropriate action by the RN? Summarize the discussion about discharge for the patient. Arrange with the patient a later time to complete the task. Request the case manager return after the dressing change to complete the plan. Proceed with the dressing change during the discharge plan discussion. 13. A patient tells the RN “I have not spoken with my family in years. I know I am dying and would like the chance to see them again.” What is the appropriate reply by the RN? “Would you like us to facilitate a family meeting?" “It is good to let go of past differences.” “I can pray with you for inner peace if you’d like.” “Do you think your past actions caused family disagreement?” 14. A nursing student comments to the RN: “I am a little behind in my patient care. Does it matter if I abstain from interprofessional rounds today?” How would the RN respond? “You do not need to participate. Your patients are able to speak for themselves.” “It is more important to provide the patient care that was assigned.” “As the patient’s nurse, you do need to contribute to the discussion.” “It’s OK not to present If your documentation is current.” 15. An RN is working in an acute care setting when there is an activation of the emergency operation plan. What is an appropriate response when a colleague asks the RN why an interdisciplinary team meeting is necessary prior to the casualties’ arrival? “We need to plan for potential security concerns, including breaches.” “To set up the method for the evaluation our response to this disaster.” “It clarifies the role of each team member for this specific event.” “There may be ethical concerns so we have to determine who can be on the team.” 16. An adolescent with uncontrolled asthma is admitted to the hospital. Which statement by the RN is the most appropriate to achieve optimal asthma control? “More education is required so this patient is compliant with the treatment plan.” “The adolescent needs counseling on how to adjust to a chronic illness.” “The adolescent and the health team need to review and revise the treatment plan.” “There are many environmental triggers which cannot be controlled for this patient.” 17. A patient receiving enteral nutrition requests to have the gastric tube removed. “I feel this feeding tube is burdensome to me; I don’t want to be fed this way anymore.” The family and several members of the health team voice concern about withdrawing treatment. What is the most appropriate course of action by the RN? Emphasize to the patient the treatment will help ease symptoms of hunger. Suggest an interprofessional meeting to discuss treatment goals. Review the patient’s end-of-life care desires with the family. Compare the effectiveness of the medical regime to evidence-based protocols. 18. A patient with diabetes is consuming a sugary drink with a pastry for breakfast and tells the RN “I do not like the hospital food so my friend stopped and got me something on the way in this morning.” What is an appropriate intervention by the RN? Provide written teaching material about the diabetic meal plan. Have the dietician meet with the patient regarding food choices. Document the patient’s non-compliance with prescribed diet. Encourage the patient to eat the foods provided on the meal tray. 19. Which finding suggests to the RN the need for an interprofessional discharge plan for the family with a newborn? The mother with lineal nigra. The infant with erythema toxicum. The infant with caput succedaneum. The mother with a previous episode of depression. 20. The parents ask the RN about long term follow-up care after surgical repair of a cleft palate for their infant. What is the appropriate response by the RN to address continuity of care? “No additional surgical follow-up is required once the surgeon discharges the baby.” “Results of surgery are usually excellent; your pediatrician will manage follow-up care.” “Follow-up care for the baby includes a team approach to identify issues as the baby grows.” “The infant will do well, however you both should undergo genetic testing.” 21. The patient says to the RN “The stress-reduction education was helpful. How can I use technology to help me reduce stress when I am at home?” Which recommendation would the RN make? “Several on-line health programs can be viewed on your computer.” “There are several video games that can provide temporary distraction.” “You can download mobile phone applications (apps) on meditation.” “A wristband fitness monitor can provide feedback on your daily activity.” 22. A parent asks the RN for internet resources that provide additional information on vaccination safety in children. How does the RN respond? “Use the search function on your web browser to look up health resources.” “It’s best to choose a web site that was authored by a physician.” “Wikipedia has free online educational articles that are easy to read.” “I recommend using a professional organization’s web site.” 23. A student nurse asks the RN “Can you provide an example of how technology improves medication administration?” What is the RN response? “When intravenous infusion smart pumps are used, errors are eliminated.” “The computerized physician order entry ensures the appropriate medication is ordered." “Having the pharmacy department fill prescriptions electronically ensures the medication doses are accurate.” “Bar code scanning helps to identify the right patient and the right medication." 24. A patient emergency occurred on a medical unit. When staff responded, an RN noted an unattended computer in the nursing station is displaying patient information. What is the initial action by the RN? Determine who was using the computer. Log the computer off. Minimize the patient care screen. Notify the risk manager. 25. What actions observed by the RN requires correction to avoid security risks to the medical electronic records? Select all that apply: Communicating with discharged clients through the client web portal. Disclosing general computer information when asked by a visitor. Using hospital computer to access personal electronic mail. Texting client information to a physician on a personal phone. Connecting a USB drive found at the nursing station to the hospital computer system. 26. Which patient would benefit most from the technology resource shown in the image below? Suburban, first-time mother with a new baby at home. Home-schooled child with Diabetes Mellitus. Rural, older adult with Parkinson’s disease. Urban, post-surgical patient recovering at home. 27. Which actions demonstrate the RN is information literate and uses technology to provide safe patient care? Select all that apply. Uses sources of information that appear to be credible. Understands complete information necessary for intelligent decision-making. Organizes information into understandable chunks. Distinguishes opinion from factual knowledge. Sorts information based in information needs. 28. Which technology used in the clinical setting by the RN has the potential to result in unsafe patient outcomes? Review care for patients with various diseases on health database. Reliance on a medical mobile application to make decisions. Use of the timer on a smart phone as a reminder to complete a task. Using a listserv to examine unfamiliar medication information. 29. Which interventions can an RN delegate to a UAP for a client who has been identified as a “risk for falling?” Select all that apply Offer the client assistance with toileting needs. Identify specific gait abnormalities when the client ambulates. Summarize the strategies taken to the client’s family. Activate a chair alarm when the client is out of bed. Review with the client the correct use of an assist device. 30. The UAP receives the delegation assignment for the shift that includes assisting the patient in Room 42 to be up in the chair for meals. The RN notes the patient was still in bed fifteen minutes after the meal tray arrived. After assisting the patient to the chair, what is the appropriate action for the RN to take next? Notify the manager that the UAP did not complete the job. Have the UAP verbalize the earlier instructions provided. Ask the UAP if the task was reviewed during orientation. Explain to the UAP why the task is important to be done. 31. An Unlicensed Assistive Personnel (UAP) was delegated the task to assist a patient from the bed to the chair. The patient slid to the floor; no injury occurred. What statement represents an appropriate response by the RN? “Remember this patient was identified as a risk to fall.” “Did you ask for help prior to the fall?” “We have a policy to use lift equipment on all patients.” “Let’s talk about what went right and what went wrong.” 32. A patient transferred from the intensive care unit (ICU) to the medical unit is assigned to a novice nurse. The nurse tells the charge nurse “I am unfamiliar with the required nursing care for a patient with this diagnosis.” What is the most appropriate response by the charge nurse? “I will have another nurse assigned to work with you.” “If you need help, ask any staff nurse.” “The patient is stable; we have confidence in you.” “The ICU nurse will review patient care with you.” 33. A newly hired unlicensed assistive personnel (UAP) has some difficulty performing comfort measures for a patient at the end-of-life. What is the appropriate response by the RN? Indicate the next time the task is delegated will be easier. No need to say anything, the UAP performed as expected. Inquire if the UAP is returning to work tomorrow. Ask the UAP to identify what went well and what did not. 34. Which statements indicate the RN communicates effectively to the Unlicensed Assistive Personnel (UAP) when delegating personal hygiene care for a patient with dementia? Select all that apply. “When hygiene activities are completed, assist the other UAPs in getting patients out of bed.” “I’ll need to know if you notice any redden areas on the skin when we regroup in two hours.” “If extra help is needed, ask another UAP for assistance.” “Assist Mrs. Smith to the bathroom on the even hours; she uses the walker for balance.” “Don’t worry if the patient refuses to shower. Hygiene activities can be done later.” 35. The RN delegated to the UAP the task of obtaining vital signs on several clients. The UAP reports: “The client in room 424 is agitated and refused to let me take the vital signs today.” Which response by the RN indicates appropriate follow-up of the task delegated to the UAP? “This is an unexpected finding; I will assess the client.” “I’ll assign another UAP to check the vital signs.” “Tell the client that vital signs need to be done.” “Take the vital signs after the client eats.” 36. Which of the following patients is appropriate for the RN to delegate to the LPN with the RN as a resource? The patient experiencing hypertension requiring treatment with intravenous medication. The patient who had a cholecystectomy awaiting discharge instructions. The patient with hepatic dysfunction requiring a review of mental status. The patient with chronic renal disease requiring assistance with self-care activities. 37. Which statement made by the RN to the Unlicensed Assistive Personnel (UAP) incorporates legal and ethical principles when delegating care? “Review proper hand hygiene with Ms. Q’s family in Room 25. If there are questions, let me know.” “Obtain the vital signs for Mr. Z. in Room 22 now. If the pulse rate is irregular, notify me promptly.” “Assist Ms. R. in Room 24 out of bed. If dizziness is reported, obtain a blood pressure.” “Place oxygen on Mr. C. in Room 21 if chest pain is reported. Obtain vital signs and notify me.” 38. The RN has asked the unlicensed assistive personnel (UAP) to encourage a child to eat who is receiving chemotherapy. Which statement made by the UAP requires the RN to intervene? “Here is some gelatin that is fun to eat.” “Rinse your mouth with warm water before eating.” “A strawberry milk shake will be cool to drink.” “Organic honey can make the food taste better.” 39. Which task is appropriate for the RN to delegate to the Unlicensed Assistive Personnel (UAP)? Showing family members how to assist the patient to the bathroom. Placement of a bed alarm whenever a patient seems confused. Helping the patient up to a chair who was on bedrest for 4 days. Measuring and recording urinary output on patients. 40. Which of the following patients requires assignment to an RN for priority assessment? An eight-year-old child with a fractured femur that was surgically repaired 2 days ago. A ten-year-old child admitted with nausea and tenderness in right lower quadrant. A five-year-old child with an infected leg wound with a scheduled dressing change. A nine-year-old child with leukemia whose parent is anxiously awaiting laboratory results. 41. Which statement by the RN is an example of an internal barrier to effective delegation? “Perfection in patient care should be the goal of all staff members.” “We need to focus the patient issues and not our personal affairs.” “Patient assignments are based on patient needs and not staff needs.” “The full nursing team is not here today, do patient rounds every other hour.” 42. Which is the most appropriate assignment for an experienced medical-surgical RN assisting in the emergency department during a mass casualty incident? A patient who is experiencing left arm discomfort, diaphoresis and anxiety. A pregnant patient who was experienced a blast injury to the abdomen. A patient with bilateral pneumonia receiving antimicrobials and oxygen. A patient with a head injury who has clear fluid draining from the ears. 43. Which of the following patients does the RN delegate to the LPN/LVN with an RN as a resource? A patient recovering from surgery with an expected discharge date tomorrow. A patient who requires a central venous catheter insertion performed at bedside. A patient who is receiving intravenous fluids for a low blood pressure. A patient who had a hip replacement requiring home-care referral. 44. When the RN makes rounds, it is noted a patient on a fluid restriction has a water pitcher at bedside. The RN asks the unlicensed assistive personnel (UAP) where the water pitcher came from. The UAP responds “The water pitcher was provided after the patient told me the health care provider said the patient could drink whatever was wanted.” What is the appropriate response by the RN to the UAP? “You should not believe everything the patient says is correct.” “You need to follow instructions the RN gives you without question.” “Before fulfilling a patient request, communicate with the patient’s RN.” “Your actions could have caused a patient emergency.” 45. A patient is admitted to the nursing unit with bilateral lower leg cellulitis, poor body hygiene and a BMI of 56. The RN leader overhears several nursing staff express “How could anyone live like that? The smell is awful!” What is an appropriate response by the RN charge nurse? “The UAP working today is good with patients like this.” “This patient obviously lives in poor conditions.” “Once the person is bathed, things will be better.” “All of our patients need to be treated with dignity.” 46. An LPN from a medical-nursing unit has been temporarily assigned to a surgical unit. Which questions should the RN ask of the LPN to determine safe patient delegation? Select all that apply. “Do you have any concerns about the care of the surgical patient?” “Do you want to be paired with an RN as a resource?” “Can you share with me your nursing experience and expertise?” “What type of supervision do you want from me?” “How would you describe your knowledge about care of the surgical patient?” 47. The RN delegated the task of weighing patients before breakfast to the unlicensed assistive personnel (UAP). During rounds, one health care provider asks “Why has this patient not been weighed?” What is the appropriate response by the RN? “That UAP is a good worker who made a mistake.” “I’ll ask the UAP to explain the reason for failing to complete the task.” “The patient will be weighed now.” “We are short staffed today and are doing the best we can.” 48. An infant with bronchiolitis has a radiological procedure ordered. Which nursing team member is most appropriate to accompany the infant to radiology? The nurse with the most pediatric experience. The nurse in charge of the unit. The nurse assigned to care for the child. The nurse with the least busy assignment. 49. For which patient should the RN delegate constant observation? The patient with heart failure who decides to stop all medical treatment. The patient who states the family is trying steal possessions by trickery. The patient who confided the intent to take medication to end his suffering. The patient with Parkinson disease who is talking to deceased family members. 50. The RN assesses a patient with diabetes who is combative and has slurred speech. While the RN continues with the assessment, what is the appropriate initial delegation to the nursing team? Instruct the unlicensed assistive personnel (UAP) to obtain vital signs. Direct the unlicensed assistive personnel (UAP) to give the patient a glass of orange juice. Have the LPN obtain an immediate capillary blood glucose level. Ask the LPN to notify the healthcare provider about the patient’s symptoms. 51. Which patient in labor would the charge nurse assign to the certified obstetrical RN? A woman requesting hydrotherapy. A woman with a spinal cord injury. A woman who presents in precipitate labor. A woman who is over 38-years-old. 52. When the RN directs the UAP to perform post-mortem care, the UAP responds by asking “Do I have to?” What is the appropriate response by the RN? “Can you tell me why you are reluctant to do this task?” “Ask another UAP to assist you with this task.” “Was the procedure reviewed as part of your general orientation?” “Yes, this task needs to be done within the next 30 minutes.” 53. An RN is caring for a patient who had a cesarean birth one hour ago. What is an appropriate task to delegate to the Unlicensed Assistive Personnel (UAP)? Identify amount of lochia. Check the height of the fundus. Review the method to breast-feed with the patient. Offer comfort measures such as a back rub. 54. The RN is delegating the task of assisting a client from bed to chair using a lift assist device to an unlicensed assistive personnel (UAP) . Which RN statement is a barrier to effective delegation? “The client does well in the reclining chair and needs to get up before meals.” “This is a new piece of equipment so let’s review the process before we start.” “Contact me before you get the client up to the chair so I can assess the client.” “If you prefer to not assist the client out of bed, I can find someone else.” 55. The RN assigns an Unlicensed Assistive Personnel (UAP) to observe a patient at risk for suicide. What instruction does the RN provide for the UAP? “Notify me if you need a break before your scheduled replacement arrives at 1700.” “Bring the patient to the nurses’ station when you take your meal break.” “Ask the family to watch the patient if you need to get linen supplies.” “If you need to leave the patient, ask another UAP to sit with the patient.” 56. An unlicensed assistive personnel (UAP) reports to the RN that a patient with chronic obstructive pulmonary disease (COPD) and respiratory failure could not be aroused when vital signs were taken. What is the most appropriate response by the RN? “Were the vital signs similar to the last ones recorded?” “Is the patient still receiving oxygen therapy?” “The patient is finally getting much needed rest.” “I will go assess the patient now.” 57. The nurse manager observes an increase in the use of the rapid response team during the weekend. What is an appropriate response to the observation? Collect more information before initiating any action. Place more staff on the weekends. Provide more education to the weekend staff. Investigate the issue using the quality improvement process. 58. A patient who was preparing for discharge after delivering a healthy baby has a cardiac-respiratory arrest and dies. Prior to participating in the quality review for the sentinel event, the RN who been caring for the patient asks the nurse manager about the purpose of the process. Which response by the manager is appropriate? “To critically review the events and identify areas for improvement.” “To identify the professional who did not follow protocol.” “To validate the components of good care we did provide for the patient.” “To meet the mandate established by the hospital administration.” 59. A student nurse asks the RN the purpose of asking patients about personal sexual preferences and orientation. How does the RN respond? “It screens for potential risk factors for other diseases.” “This ensures staff does not make inappropriate remarks.” “Behaviors that signal sexual dysfunction can be identified that way.” “The patient assessment data set in the electronic health record requires it.” 60. The RN notes unlicensed assistive personnel (UAPs) use a great deal of time seeking to find a wheeled walker to assist ambulating patients with an unsteady gait. Additionally, there is only one walker being used several patients. Which action demonstrates the RN considered components that influence the quality improvement process? Discuss the need for additional resources with the nurse manager. Tell the health care provider about the problem ambulating patients. Ask the patient’s family to bring the personal walker from home to use. Have the patient push a portable intravenous pole when walking in the hall. 61. The most frequent complaint that appeared on patient satisfaction surveys was the noise level. A RN wants to present a research article that demonstrated increased patient satisfaction after one hour of designated “quiet time” was established on the nursing unit. What is the appropriate initial step the RN should take regarding possible redesign of the health care setting to improve the patient environment? Ask patients to rate how helpful the proposed policy would be for them. Discuss the purpose and goal of the project with the nurse manager. Post a sign indicating the quiet time policy throughout the unit. Actively seek out approvals from the nursing team in support for the change. 62. What method evaluates the effectiveness of a nursing unit’s quality improvement project on hand hygiene? Patient feedback about staff’s behavior. An educational exam taken by staff that measures infection control. Random observation of staff’s practice. The healthcare-associated infection rates for the nursing unit. 63. A nursing student asks the RN why the Braden Scale for Predicting Pressure Sore Risk is used and documented every shift. Which statements support the need for a systematic approach to risk reduction? Select all that apply. Using a reliable tool is a proven method to eliminate all pressure ulcers. Medicare will not reimburse for care required to treat hospital acquired conditions. Regular assessment identifies patients who may develop impaired skin integrity. Applying evidence-based nursing interventions improve patient care outcomes. A review of the electronic health record can help identify staff do not following protocol. 64. A patient who received moderate sedation for a colonoscopy required use of a reversal agent to prevent a pending respiratory arrest. Which statement indicates the RN is appropriately addressing the “near miss”? “We need to ensure the documentation shows we monitored the patient very closely.” “The patient needs to be identified as ‘sensitive’ to the medication that was administered.” “I think we need to start giving intermittent doses of sedating medication.” “A review of this patient situation will improve this process and procedure.” 65. A co-worker tells the RN “I did not sleep well last night; all I dreamt about was the ringing of the patient alarms. Do you think others have this problem?” Which response by the RN demonstrates a focus on providing insight to enhance patient care? “Yes, the alarm noises can be annoying. Patient room should be soundproofed.” “Yes, it is noisy. Eventually though it seems like I don’t even hear the alarms.” “This would be a good topic to discuss with the quality improvement team.” “New employees probably need additional education on alarm systems.” 66. A unit secretary who is pregnant asks the RN “Should I get the influenza vaccine? I do not provide care for patients.” Which statement indicates the RN understands Centers for Disease Control and Prevention (CDC) guidelines? “No, the vaccine is mandated for direct care health care providers.” “Yes, the vaccine reduces the possibility of getting ill and infecting others.” “Yes, the health administrators made the vaccine mandatory for all staff.” “No, pregnant staff members should not receive the vaccine.” 67. During a quality improvement meeting, a RN shares a nursing research article that outlines a longer injection technique decreases patient’s report of pain after receiving subcutaneous heparin. Which data collection method would be utilized in the plan of change to evaluate the effectiveness of applying the evidence-based research findings to nursing practice in this circumstance? Numeric Rating Scale Verbal information from RNs Medication administration records Patient satisfaction surveys 68. An RN tells the charge nurse: “I’m lucky my client refused to take the medication. I would have made a medication error if it was taken.” Which response demonstrates the charge nurse’s competency in risk reduction? “An occurrence report needs to be done to help improve our systems.” “So you don’t have to be disciplined, this event stays between the two of us.” “No additional action is required as no mistake happened.” “This is a good example how short staffing causes problems.” 69. Which nursing intervention is included in the evidence-based tool or “bundle” of activities that are associated with prevention of ventilator associated pneumonia (VAP)? Elevate the head of the bed to 15 degrees. Routine suctioning every 2 to 4 hours. Brush the patient’s teeth twice a day. Instill saline in airway to loosen secretions. 70. The operating RN is preparing the operating room prior to a patient’s scheduled joint replacement surgery. The RN becomes aware that all the required equipment is not available. What action would prevent future occurrence of a similar event? Develop a team to review the events and make recommendations. Have the surgeon check the equipment prior to making an incision. Incorporate the use of a separate pre-procedure documentation form. Identify the person who did not order the proper equipment. 71. A patient who received an intravenous (IV) anticoagulation medication experienced an acute gastrointestinal bleed. What is an appropriate action by the RN? Document in the patient’s electronic record that incorrect medication was given. Inform the patient the anticoagulant medication caused the acute bleed. Complete an occurrence/incident report to trigger a quality improvement action. Share the interventions performed after the event with the nurse manager. 72. A visitor who smells of alcohol and has an ataxic gait, loudly requests to talk to the RN. What action by the RN indicates understanding of standards and regulations for a healthy workplace environment? Quietly initiate the institution’s safety protocol. Encourage the visitor to be calm and to sit down. Guide the patient with a light touch away from patients. Lead the person into a private room to discuss concerns. 73. A patient whose primary language is Spanish is scheduled for discharge to home. A new prescription for warfarin was written. What demonstrates the RN’s application of evidence-based standards to promote a safe discharge? Provide written material on the medication. Make a referral to home care. Ask the patient if they can read and understand English. Develop a teaching plan that includes a trained interpreter. 74. The nursing unit quality improvement committee identified a unit goal of decreasing noise at night. Which of the following actions by the RN can help achieve the goal?. Disable a predetermined number of bedside alarms. Maximize the oxygen saturation alarm parameters. Decrease the sensitivity of the clinical alarm systems. Assess patient need for clinical alarm systems daily. 75. Which action indicates the RN applies clinical recommendations to decrease catheter associated blood stream infections (CLABSI)? Assess the patient’s need for the catheter on a daily basis. Remove the transparent dressing daily to inspect insertion site. Routinely scrub the injection port with povidone-iodine. Flush the catheter every 12 hours with a 5 mL syringe of normal saline. 76. A patient’s spouse asks the RN “What should be done at home so this Clostridium difficile my spouse has doesn’t infect the rest of the family?” Which response indicates the RN applies the Center for Disease Control and Prevention (CDC) recommendations? “Bed linens used by the patient should be discarded.” “No action is required. The bacterium is not harmful outside the body.” “Wipe down environmental surface areas using a bleach solution.” “All close family members should be screened for the infection.” 77. A recently hired RN asks the preceptor “Why are vital signs obtained every 4 hours at night on patients who are stable? Research suggests patients benefit from uninterrupted sleep at night.” Which response by the preceptor reflects application of research into practice? “We tried that before in the past and it did not work.” “Those studies were done on less acutely ill patients than our patients.” “Most research studies do not apply in the clinical setting.” “Let’s discuss the research findings with the manager.” 78. The nursing staff are discussing the challenges associated with an increasing population of patients with severe obesity. What is the appropriate action? Bring forward concerns to the unit-based quality improvement team. Request an increase in unlicensed assistive personnel (UAP) staff to help with care. Obtain further education on safe lifting practices. Discuss concerns during interprofessional rounds. 79. As the RN is completing the admission process, the patient states “I need my pain medication now. I brought it with me.” The health care provider has not prescribed any analgesics. What is the appropriate action by the RN? Assess the patient’s pain and communicate the information to the health care provider. Suggest the patient self-medicate with tablets brought from home while waiting for orders. Tell the patient the medication will be dispensed once the previous order is verified in the electronic health record. Determine if there is any prescribed medication that can be substituted. 80. One RN tells an RN co-worker “My patient’s spouse looks at me in a way that makes me feel very uncomfortable.” Which response by the RN reflects professional nursing guidelines regarding social boundaries? “Just avoid the spouse and the behavior will eventually stop.” “If it will make you feel better, I’ll switch assignments with you.” “You need to discuss the situation with the nurse manager.” “I think you are overly sensitive; I have not experienced that feeling.” [Show More]

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