Question

A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

Answer 1

Correct Answers:

Requesting a referral for the client to attend reminiscence therapy sessions

Rationale :

🌟Advocating for a client means supporting their rights and ensuring they receive appropriate care aligned with their needs and values.

🌟 Requesting a referral for reminiscence therapy reflects client advocacy because it promotes a nonpharmacological intervention that can enhance the quality of life and cognitive stimulation for clients in early-stage Alzheimer's.

🌟 It also shows the nurse is taking an active role in coordinating services that the client may not be able to request for themselves due to impaired memory or judgment.

🌟 Advocacy includes anticipating client needs and ensuring access to supportive services they may benefit from but cannot seek independently.

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Answer 2

Correct Answers:

The client's code status

Rationale :

🔹In the SBAR (Situation, Background, Assessment, Recommendation) communication format, the Background section includes pertinent medical history, current diagnoses, allergies, and code status.

🔹 The code status is critical background information that informs the receiving team about the level of intervention the client should receive during an emergency, such as whether to perform CPR or intubation. Including this in the background ensures continuity of care and prevents delays or errors in emergency treatment.

Other details, like current vitals or prescribed consultations, belong to different parts of the SBAR format.

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Answer 3

Correct Answers:

Determine the reasons the nurses are not taking scheduled breaks

Rationale :

💥When addressing a concern like missed breaks, the nurse should follow the nursing process, beginning with assessment.

💥Determining why the nurses are skipping breaks is essential to identify whether the issue stems from staffing shortages, workload distribution, or personal choices.

💥Acting without this information could lead to ineffective solutions.

💥 Identifying root causes helps the charge nurse implement targeted interventions to support staff wellness and ensure compliance with labor and safety standards.

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Answer 4

Correct Answers:

A client who has peripheral vascular disease and has an absent pedal pulse in the right foot

Rationale :

🌐An absent pedal pulse in a client with peripheral vascular disease (PVD) may indicate acute arterial occlusion, which is a limb-threatening emergency that can result in tissue necrosis if not promptly treated.

🌐This condition requires immediate assessment and intervention to restore circulation.

🌐Other options, such as MRSA with fever or postoperative urinary retention, are concerning but not as immediately life-threatening.

🌐This prioritization reflects the ABC framework and urgency in addressing circulation compromise.

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Answer 5

Correct Answers:

A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump

Rationale :

◼A nurse floating from a medical-surgical unit should be assigned to stable clients with predictable care needs, preferably with conditions similar to those on a med-surg unit.

◼A postoperative Cesarean client with a PCA pump represents a situation that closely resembles surgical recovery patients on medical-surgical floors.

◼This client is likely to need pain management and postoperative monitoring, both of which fall within the skill set of a med-surg nurse.

◼Clients in labor, with gestational complications, or at risk for preterm labor require specialized obstetrical training and experience.

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Answer 6

Correct Answers:

Administer a bronchodilator two times a day for a child who has cystic fibrosis.

Rationale :

🎇Cystic fibrosis (CF) requires aggressive pulmonary management, including frequent airway clearance and bronchodilator therapy.

🎇Administering a bronchodilator only two times a day is inadequate and does not align with current best practices, which often include more frequent dosing to optimize airway clearance and reduce mucus accumulation.

🎇Children with CF benefit from scheduled treatments that may occur before meals and chest physiotherapy to facilitate mucus clearance.

🎇 The care plan should be revised to reflect the standard of care for this chronic, life-limiting condition.

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Answer 7

Correct Answers:

Suctioning a client's long-term tracheostomy

Rationale :

⭐Assistive personnel (APs) can safely perform suctioning of a stable, long-term tracheostomy, especially when the procedure is non-complex and routine in nature.

⭐ In such cases, suctioning is considered a delegable task under the nurse’s supervision.

⭐ However, the RN remains accountable for assessing the client's respiratory status before and after the procedure.

⭐ In contrast, using a pain scale, instructing clients, or managing central lines are complex assessments or interventions that fall within the RN’s scope.

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Answer 8

Correct Answers:

Impaired voluntary cough

Rationale :

✔An impaired voluntary cough suggests a swallowing impairment, putting the client at high risk for aspiration, particularly post-stroke.

✔ The nurse should initiate a referral to a speech-language pathologist (SLP), who evaluates swallowing function and helps reduce the risk of aspiration pneumonia.

✔This symptom is a red flag indicating dysphagia, even more critical than motor or eye findings.

✔ Timely intervention helps maintain airway protection and nutritional status, both of which are vital in stroke recovery.

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Answer 9

Correct Answers:

Determine the UAP's knowledge about HIV transmission.

Rationale :

🔸When a staff member expresses fear or hesitation about a task, the nurse should first assess their understanding.

🔸Fear of collecting a sputum sample from an HIV-positive client may stem from misconceptions about transmission, so determining the UAP’s knowledge allows for targeted education.

🔸By clarifying any misinformation, the nurse promotes a safer, more competent work environment and reduces stigmatization of clients with infectious diseases.

🔸 This approach follows the nursing process—assessment first.

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Answer 10

Correct Answers:

Decreased level of consciousness

Rationale :

🦠In a client with meningitis, a decreased level of consciousness is an urgent sign of increased intracranial pressure (ICP), which can indicate worsening neurologic function and potential brain herniation.

🦠 It requires immediate reporting and intervention to prevent life-threatening complications.

🦠Other findings like photophobia or rash are expected and not as critical as altered mental status.

🦠Rapid identification and treatment of neurological deterioration are essential in preventing permanent damage or death.

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RN Leadership 2023 Exam 3

No.

1 : A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

2 : A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

3 : A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?

4 : A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?

5 : A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

6 : A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?

7 : A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

8 : A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?

9 : A newly hired unlicensed assistive personnel (IJAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

10 : A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

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