Question 1

The nurse is talking with the family of an 18 month-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is?

Accepted Answer

Answer reason: Genetic counseling helps determine inheritance risk, need for screening of other children, and guidance about genetic testing. This is a priority communication need early because it directly affects immediate family planning and surveillance decisions. The other options emphasize worst-case outcomes or incorrect prognostic framing rather than providing actionable, evidence-based guidance.

Question 2

A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?

Accepted Answer

Answer reason: A mentor who functions as a teacher-coach actively facilitates learning, helps translate administrative concepts into practice, and supports progressive autonomy. Clarifying information and accepting feedback are helpful behaviors, but they are secondary outcomes of a well-functioning coaching relationship rather than the defining priority characteristic. Random assignment by administration does not ensure a good fit, trust, or relevant expertise, which undermines mentoring effectiveness.

Question 3

A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is?

Accepted Answer

Answer reason: The statement that the manager “makes all decisions and rarely asks for our input” directly matches this style. A participative/democratic manager would intentionally seek staff contributions to decisions and shared governance. Laissez-faire leadership would be marked by minimal direction and limited managerial involvement rather than strong unilateral control.

Question 4

The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?

Accepted Answer

Answer reason: This option reflects shared accountability for outcomes, which is central to shared governance and professional nursing autonomy. In contrast, decisions controlled by an appointed board or non-nurse managers reflects centralized, hierarchical management rather than shared authority. Merely having appointed staff groups is not the same as shared governance, which relies on ongoing nurse-led councils/structures with real decision-making power. aims to improve quality, engagement, and patient outcomes through nursing participation in governance.

Question 5

A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is to?

Accepted Answer

Answer reason: Brainstorming relies on temporarily suspending criticism so participants can generate a wide range of ideas without fear of being judged. Addressing the critical behavior in the moment protects psychological safety and keeps the group process aligned with brainstorming ground rules. Redirecting to withhold judgment preserves idea flow and prevents premature evaluation that can silence quieter staff and reduce creativity. Moving on or praising the critic does not correct the process problem and risks reinforcing unproductive group dynamics.

Question 6

Which statement describes strategies that help build personal power in an organization?

Accepted Answer

Answer reason: Networking and mentoring intentionally develop social capital and expertise, while coalition building creates shared support to move initiatives forward despite limited formal authority. This approach aligns with evidence-based leadership practices that emphasize collaboration and mutual goals rather than coercion. A confrontational style more often undermines trust and can erode influence, and professional appearance supports credibility but is not a core strategy for building power compared with relationship-based influence.

Question 7

During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach?

Accepted Answer

Answer reason: Facing the client supports rapport, allows assessment of understanding via nonverbal cues, and keeps teaching patient-centered while the interpreter provides language conversion. Speaking directly to the interpreter can shift attention away from the client and impair assessment of comprehension. Using family members or leaving the client alone with the interpreter increases risk for inaccurate translation, loss of confidentiality, and compromised informed decision-making.

Question 8

The nurse recognizes that the most effective way to resolve a conflict is through?

Accepted Answer

Answer reason: Effective conflict resolution in healthcare prioritizes collaboration to meet shared goals (patient safety, team functioning) while addressing the underlying needs of all parties. A collaborative “win-win” approach (problem-solving) seeks the root cause, promotes open communication, and results in solutions both sides support, improving buy-in and reducing recurring conflict. Compromising often yields a “lose-lose” partial satisfaction where important needs may remain unmet. Avoiding and accommodating can temporarily reduce tension but commonly leave the core issue unresolved and can worsen resentment or safety risks over time.

Question 9

The nurse is planning the care of the client with Meniere’s disease. With which member of the interdisciplinary team should the nurse expect a consultation?

Accepted Answer

Answer reason: The specialist most directly responsible for diagnosing and managing inner ear pathology (including audiologic testing, medical therapy such as diuretics/vestibular suppressants, and consideration of procedures) is an ENT physician. Other specialties listed do not primarily manage vestibular/inner ear disease. While therapy may be helpful for balance rehabilitation, the expected primary consultation for disease management is to the ENT service.

Question 10

The office nurse is caring for the client diagnosed with chlamydia and syphilis. Based on this diagnosis, which medication order would require the nurse’s immediate review with the prescribing HCP?

Accepted Answer

Answer reason: Chlamydia is typically treated with doxycycline or azithromycin, and syphilis is treated with penicillin G (with doxycycline as an alternative in penicillin-allergic, nonpregnant clients). Metronidazole targets anaerobes and protozoa and is used for conditions like trichomoniasis and bacterial vaginosis, not for chlamydia or syphilis. Therefore, this order does not match either diagnosed infection and should be clarified promptly to avoid undertreatment and ongoing transmission. A common distractor is doxycycline, which can appropriately treat chlamydia and can be an alternative regimen for certain stages of syphilis when penicillin cannot be used.

Question 11

Which is an example of a staff nurse functioning in the role of an informal leader?

Accepted Answer

Answer reason: Encouraging a colleague to participate in a committee shows peer-to-peer influence that advances unit goals and professional engagement. Verifying staffing coverage and issuing discipline are formal management functions tied to supervisory authority and organizational responsibility. Attending a hospital-wide policy meeting may reflect participation, but it does not inherently demonstrate influencing peers, which is the hallmark of informal leadership.

Question 12

Which of the following activities is an example of an indirect care function of a home health nurse?

Accepted Answer

Answer reason: Team conferences are a care-coordination activity used to share assessments, align goals, and update the interdisciplinary plan, which directly fits the definition of indirect care. In contrast, confirming a client’s condition and teaching a family are direct-care activities because they involve direct assessment or client/family interaction aimed at immediate care needs. Observing a home health aide is supervision that may support quality, but the clearest indirect care example listed is interdisciplinary conferencing focused on care planning and coordination.

Question 13

Family members report exhaustion and difficulty taking care of a dependent family member. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Caregiver role strain requires an interprofessional, resource-focused plan that supports safe ongoing care while respecting the client’s needs and capabilities of the family. Organizing a family conference allows shared decision-making, clarifies goals, and identifies specific care gaps and support options. Social services can connect the family to community resources such as respite care, home health services, financial assistance, and long-term care planning. Simply having the family discuss the issue without guidance or directing placement to a facility bypasses assessment, client preferences, and available supportive alternatives.

Question 14

A team leader notes increasing unrest among the staff members. Which action is best for the team leader to take?

Accepted Answer

Answer reason: Effective team leadership addresses conflict early through open, structured communication that promotes psychological safety and shared problem-solving. Convening the group allows the leader to clarify observations, invite staff perspectives, and identify root causes before morale and patient care are affected. Discussing only with one coworker risks gossip and incomplete information, which can worsen mistrust. Escalating to the manager may be appropriate if the issue persists or involves policy/discipline, but the leader should first attempt direct, collaborative resolution. Ignoring the situation is unsafe because staff unrest can impair teamwork, increase errors, and compromise care.

Question 15

A nursing student asked the instructor for the best example of an appropriate nursing care delivery system. The best response by the instructor would be?

Accepted Answer

Answer reason: ICU patients typically require multiple, time-sensitive interventions (e.g., titrated drips, frequent assessments, device management), making a team approach efficient and safe. Team nursing leverages the RN’s assessment and clinical decision-making while appropriately distributing tasks to other team members to maintain continuous coverage. In contrast, case management is focused on coordinating care across settings and length of stay rather than delivering bedside nursing in a high-turnover emergency environment.

Question 16

The client is going home with a new prescription of fluticasone/salmeterol diskus. The client has never used a diskus delivery system before. Which member of the health care team should the nurse consult to instruct the client in the proper use of the diskus?

Accepted Answer

Answer reason: Respiratory therapists are specifically trained to teach and evaluate inhaler technique, including device-specific steps such as loading doses, coordinating inhalation, and confirming inspiratory flow for dry-powder systems. Consulting this specialist supports safe, effective discharge teaching and reinforces correct technique through return demonstration. A pharmacist is an excellent resource for medication counseling and adverse effects, but device technique training is most directly within respiratory therapy expertise.

Question 17

The HCP notifies the nurse that the client will be discharged from the hospital tomorrow. The client is unable to ambulate to the bathroom independently, lives alone, and has a poor appetite. With which discipline is it most important for the nurse to collaborate for discharge planning?

Accepted Answer

Answer reason: Living alone with impaired mobility creates immediate needs for home health services, durable medical equipment, possible caregiver support, and assessment of home safety—coordination that is led by social work/case management. Social work can rapidly arrange community resources, transportation, and follow-up services, reducing risk of falls, neglect of self-care, and readmission. While therapy and nutrition consults are helpful, they do not address the broader social supports and services that are the primary barriers to a safe discharge.

Question 18

TWO years ago, the older adult client was diagnosed with CRF requiring dialysis. The client is admitted to a hospital with pneumonia for the third time in the last 9 months. Which health care team member should the nurse consult to enable the client to cope with a chronic disease?

Accepted Answer

Answer reason: The social worker is the interprofessional team member best suited to assess coping, support systems, financial/insurance barriers, transportation, home services, and community resources that can improve adherence and reduce recurrent admissions. This consult supports adjustment to chronic renal failure and frequent hospitalizations by addressing stressors that worsen health outcomes. A dialysis nurse focuses on dialysis-specific education and treatment, but does not primarily provide the broad psychosocial and resource coordination needed to strengthen coping.

Question 19

A new graduate nurse identifies an abnormal heart sound while performing a client assessment. The graduate nurse asks the charge nurse to listen to the client’s heart sounds. The charge nurse confirms that the client has a systolic heart murmur. This action by the graduate nurse is an example of?

Accepted Answer

Answer reason: Consultation is the process of seeking input or confirmation from a more experienced clinician to validate findings and guide next steps in care. The new graduate recognizes a possible abnormal assessment finding and appropriately requests the charge nurse’s assessment to verify the murmur, improving accuracy and patient safety. This is not delegation because no task is being assigned for the charge nurse to complete independently; it is a request for expert clinical input. It also differs from supervision, which involves overseeing another’s performance over time rather than obtaining a second opinion on a specific finding.

Question 20

The HCP prescribes cyclobenzaprine 30 mg orally tid for the client hospitalized with acute cervical neck pain. The pharmacy supplied 10-mg tablets. Which action by the nurse is best?

Accepted Answer

Answer reason: Cyclobenzaprine immediate-release is typically dosed 5–10 mg three times daily, with a usual maximum of 30 mg/day, so an order for 30 mg three times daily (90 mg/day) is outside the standard range and suggests a prescribing error or need for clarification. Administering three tablets would carry a high risk of excessive CNS depression and anticholinergic adverse effects (e.g., sedation, confusion, falls). Monitoring for drowsiness is appropriate after correct dosing but does not address the unsafe order, and giving IV morphine adds further sedation/respiratory depression risk rather than correcting the primary safety issue.

Question 21

The nurse receives the written laboratory results of a positive pregnancy test for the client scheduled for an emergency appendectomy. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Pregnancy status immediately affects perioperative decision-making because anesthesia exposure, imaging choices, positioning, and fetal/maternal monitoring plans may need urgent modification. In an emergency appendectomy, the surgeon must promptly integrate this information to balance time-sensitive treatment with pregnancy-specific risk reduction and appropriate consults. The nurse’s priority is rapid communication to the provider directing the procedure so care can be adjusted without delaying necessary surgery. Verifying the lab or notifying the primary care provider can occur afterward, and disclosure to the client is important but does not replace the immediate need to inform the operative team to prevent avoidable harm.

Question 22

The nurse is teaching the client who is hard of hearing and wears bilateral hearing aids. Which action by the nurse would best evaluate the teaching on how to change a urinary drainage bag?

Accepted Answer

Answer reason: This method also allows the nurse to observe aseptic technique, bag positioning, and prevention of contamination—key elements for preventing CAUTI and leakage. Asking for questions or providing a handout assesses receptiveness and access to information, not actual ability to do the procedure. Having the client verbally list steps checks recall but can miss technique errors, which is especially important when teaching a hands-on task.

Question 23

A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. The nurse determines teaching is successful when the client makes which statement?

Accepted Answer

Answer reason:  Beta-thalassemia trait is an autosomal recessive condition, so two carriers have a significant risk of having a child with beta-thalassemia major. Preconception genetic counseling provides risk assessment, partner testing confirmation, and discussion of reproductive options and prenatal testing. Iron supplementation is not a routine treatment for thalassemia trait and can be harmful if it leads to iron overload. Vitamin B12 injections address pernicious anemia/megaloblastic anemia, not thalassemia, and ancestry-based reassurance is incorrect because carrier status (not ethnicity) determines genetic risk.

Question 24

A physical therapist has instructed the nursing staff in range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable performing the exercises that result in crying and grimacing of the client. What is the most important action for the nurse to take?

Accepted Answer

Answer reason: The key principle is that delegated or interdisciplinary therapies must be supported by an authorized plan/order and performed within the nurse’s scope and competency. Verifying the provider’s orders clarifies that ROM is prescribed, the frequency/intensity is appropriate for an infant with torticollis, and whether parameters or precautions exist when the infant shows discomfort. Crying and grimacing can occur with stretching but also can signal excessive force or improper technique, so confirming the order is the safest first step before escalating or modifying care. Calling providers or stopping therapy may be necessary later, but verifying the authorized plan and expectations is the immediate priority for safe, coordinated care.

Question 25

Staff from two different departments are disagreeing over the transfer process between their respective departments. Which is the best process to handle this disagreement?

Accepted Answer

Answer reason: Interdepartmental conflict about a workflow is best addressed first with a collaborative, structured problem-solving process that clarifies the actual breakdowns and shared goals. Bringing frontline staff together to identify key issues surfaces real handoff barriers (communication gaps, unclear responsibilities, timing, documentation) and builds buy-in for a workable transfer standard. Escalating immediately to the director for a new policy is premature and can create a top-down mandate without understanding root causes. Allowing staff to “work it out” without facilitation risks ongoing inconsistency and patient-safety problems, while limiting it to managers can miss practical operational details known by those doing the transfers.

Question 26

The emergency department (ED) staff report not receiving enough information from long-term care (LTC) facilities that are transferring clients. What is the best approach?

Accepted Answer

Answer reason: The core management principle is to address recurring communication gaps by creating a standardized, shared handoff process between organizations to protect continuity and safety of care. A joint meeting allows both ED and LTC stakeholders to agree on required transfer data (e.g., diagnoses, code status, current meds, allergies, baseline cognition/function, recent vitals/labs) and to implement tools like a transfer checklist or SBAR form. This systems-level approach reduces variability and prevents delays or errors that occur when critical information is missing on arrival. Telling ED staff to “call for what is needed” is reactive and inconsistent, and calling an LTC director is punitive and unlikely to produce sustainable process improvement without collaboration.

Question 27

The nurse finds the client in respiratory distress with a decreasing level of consciousness and calls the ART. The ICU nurse is on the ART. Which action demonstrates that the ICU nurse is a resource to the nurse on the medical unit?

Accepted Answer

Answer reason: Being a resource in a rapid-response situation means supporting the primary nurse’s clinical judgment through expert assessment, interpretation of findings, and coordinated planning. Reviewing assessment findings together promotes shared situational awareness and helps the team rapidly identify deterioration patterns and needed interventions (e.g., airway support, escalation of care). This action strengthens collaboration without bypassing the bedside nurse’s role or fragmenting communication. In contrast, independently calling the provider or taking over tasks can undermine coordination and does not directly develop the unit nurse’s decision-making in the moment.

Question 28

The 25-year-old client with an SCI is sharing with the nurse that he is worried about how his family will be able to survive financially until he can go back to work. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Addressing financial survival after a disabling injury is primarily a care-coordination and resource-access problem requiring interprofessional referral. A social worker is the appropriate team member to assess eligibility, help complete applications, and connect the client to short- and longer-term income supports (e.g., disability benefits, Medicaid/charity programs, community resources). This intervention directly targets the client’s stated concern (family finances during inability to work) with the most immediate, practical pathway. Other referrals may provide education, rehabilitation, or advocacy support but do not most directly secure income replacement in the near term.

Question 29

A client diagnosed with cardiomyopathy saw a posting on the Internet describing research about a new herbal treatment for the disorder. When the client asks about this research, which response by the nurse is most appropriate?

Accepted Answer

Answer reason: " Safe patient education requires evaluating the credibility of health information and avoiding endorsement of unproven therapies. Herbal products can have variable potency and clinically important interactions with cardiac medications, so the nurse should encourage verification with the healthcare provider managing the cardiomyopathy. This response supports interdisciplinary decision-making and protects the client from harm while still validating their interest in learning. In contrast, endorsing internet content as reliable or making absolute claims about treatment options is inaccurate and unsafe.

Question 30

The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client's anxiety?

Accepted Answer

Answer reason: " An ileoanal reservoir (IPAA/J-pouch) is specifically designed to allow intestinal contents to pass through the anus, avoiding a long-term external ostomy. Telling the client they will have a permanent ileostomy is inaccurate and can significantly increase preoperative fear and anxiety about body image and lifestyle changes. While a temporary diverting ileostomy may be used during healing in some cases, the intended outcome of this procedure is not a permanent stoma. The RN should correct the misinformation and reinforce the expected postoperative plan and possible temporary measures in clear, supportive language.

Question 31

A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus—host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?

Accepted Answer

Answer reason:  GVHD reflects an allogeneic donor immune response that can also produce a beneficial graft-versus-leukemia/lymphoma effect, lowering relapse risk in hematologic cancers. Mild, controlled GVHD may therefore be viewed as evidence of donor immune activity against malignant cells, even though severe GVHD is harmful and requires treatment. Autologous transplants do not cause GVHD, making that statement incorrect. The best response is accurate, clarifies the concept for the orientee, and supports safe interdisciplinary understanding of transplant outcomes.

Question 32

The client is hospitalized for GI bleeding. The client’s family tells the nurse the client has a history of drinking four to eight beers every day. The client lives alone, is unemployed, and is uninsured. Which collaborative action provides the best overall client care?

Accepted Answer

Answer reason: This client has an active GI bleed risk, heavy daily alcohol use with potential withdrawal, and major social barriers (living alone, unemployed, uninsured) that require multiple disciplines to create a safe discharge and follow-up plan. A team review integrates medical management, withdrawal prevention, nutrition, and resource planning rather than focusing on only one domain. While case management, chemical-dependency services, and social work are all appropriate, the broad multidisciplinary approach best ensures comprehensive, prioritized, and coordinated care.

Question 33

Studies show that collaboration between the members of a multidisciplinary health care team improves quality of client care, decreases length of stay in health care facilities, and decreases the cost of health care to the client. Which members of the multidisciplinary team are responsible for collaboration in client care?

Accepted Answer

Answer reason: Interprofessional collaboration is a shared responsibility across all disciplines involved in planning, delivering, and evaluating care. Each team member contributes unique assessments and interventions, so effective coordination requires mutual communication and shared decision-making among everyone involved. Limiting responsibility to only a physician/case manager or nurse/case manager wrongly implies collaboration is delegated to a subset rather than integrated across the team. Including only physicians and the case manager also omits key contributors such as nursing, therapy, pharmacy, and social work who must coordinate to prevent gaps and duplications in care.

Question 34

The nurse is checking the medical records of second-trimester clients for newly prescribed medications. The nurse should contact the HCP regarding incomplete information for which prescription?

Accepted Answer

Answer reason: Magnesium sulfate for severe preeclampsia is typically administered IV (loading dose followed by continuous infusion) with explicit monitoring parameters (e.g., respiratory rate, deep tendon reflexes, urine output) and toxicity precautions (calcium gluconate availability). An IM route with only a blood-pressure trigger is incomplete and atypical for this indication, leaving critical administration and monitoring details unspecified. By contrast, the other prescriptions provide a complete dose, route, and frequency that can be implemented as written.

Question 35

The nurse reviews the plan of care for the client with COPD and limited mobility. The nurse notes that the physical therapist changed the plan to progress the client's ambulation from 100 to 200 feet twice a day. Which intervention should the nurse implement to ensure that the client's needs are met?

Accepted Answer

Answer reason: With COPD, ambulation progression can precipitate dyspnea and hypoxemia, so the therapist needs up-to-date respiratory status (e.g., baseline SpO2/oxygen needs, breath sounds, exertional tolerance) to pace activity and plan rest periods. This action supports coordinated care while still allowing appropriate mobility advancement. Requiring the nurse to be present is unnecessarily restrictive and does not address the core need for clinical information exchange, and escalating to the HCP is not indicated for a routine therapy progression when the plan can be coordinated through team communication.

Question 36

A physician prescribes an oral antidiabetic medication and weekly glucose monitoring for a 42-year-old male client recently diagnosed with type 2 diabetes. The client is moderately overweight and has a poor diet and a stressful job. He asks how his diagnosis will affect his life. What is the best response by the nurse?

Accepted Answer

Answer reason: “I’ll refer you to a diabetes nurse educator. She’ll help you develop a plan.” Type 2 diabetes management requires individualized education and sustainable lifestyle changes alongside medication, and the nurse should respond with supportive, collaborative planning. Referring to a diabetes educator appropriately mobilizes an interprofessional resource to build a personalized plan for nutrition, activity, monitoring, weight management, and coping with stress. This approach also aligns with patient-centered care by addressing the client’s broad concern about how life will change rather than giving a narrow directive. In contrast, minimizing the need for change is inaccurate, and prescriptive advice (snacking or changing jobs) is premature and not tailored to assessed readiness and resources.

Question 37

The client with type 1 DM is scheduled for major surgery in the morning. The nurse on the night shift observes that the client’s daily insulin dose remains the same as previously given. Which nursing action is most appropriate?

Accepted Answer

Answer reason: Perioperative insulin management requires individualized provider orders because NPO status, surgical stress hormones, and IV dextrose/fluids can rapidly alter glucose needs while type 1 clients must still receive basal insulin to prevent ketoacidosis. The safest nursing action is to collaborate with the prescriber to clarify and update the insulin plan rather than independently altering or holding doses. Nurses cannot write or change medication orders, making dose reduction an unsafe and out-of-scope action. Holding insulin based on a single “normal” glucose risks ketosis/hyperglycemia and is not an appropriate standing nursing decision without an order.

Question 38

The nurse is caring for multiple clients with DM. It is most important for the nurse to initiate a referral to a diabetes educator for which client?

Accepted Answer

Answer reason: A markedly elevated A1c indicates poor long-term glycemic control and a high risk for microvascular and macrovascular complications, even if spot glucose readings appear acceptable. A discordance between the client’s perception (“well controlled”) and objective data signals a major knowledge/skill gap in self-management, making diabetes education a priority referral. Diabetes educators can address monitoring, nutrition planning, medication needs, and problem-solving to reduce sustained hyperglycemia. By comparison, an A1c of 5.6% reflects non-diabetic/near-normal average glucose and does not represent an urgent education need relative to uncontrolled disease. The client with A1c 7% is closer to typical targets and is less urgent than severe uncontrolled control.

Question 39

The nurse is caring for the toddler who has been hospitalized for observation because of apnea spells that have led to cardiac arrest at home three times in the past 6 months. The nurse suspects Munchausen Syndrome by Proxy (MSP) and contacts the “CF,” who does not believe that this is a correct assessment of the condition of the child or of the family dynamics. What should the nurse do?

Accepted Answer

Answer reason: Suspected factitious disorder imposed on another is a high-risk child-safety concern that requires coordinated, interprofessional assessment and a unified plan to protect the child and document findings. A case conference brings together nursing, medical, and social work perspectives to reconcile disagreement, review objective data, and initiate appropriate safeguarding actions (including referral to protective services per policy) without relying on a single skeptic’s opinion. Escalating only to a department head or charge nurse does not ensure the full team evaluates the risk or that protective resources are engaged. A variance report is not the primary immediate action for suspected abuse; the priority is collaborative management and child protection planning.

Question 40

An enema is prescribed for a client with suspected appendicitis. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Enemas are contraindicated when appendicitis is suspected because increasing intraluminal pressure and stimulation of bowel activity can raise the risk of appendix rupture and peritonitis. Nursing safety principles require holding and clarifying potentially harmful prescriptions before carrying them out. Interventions like preparing solution, positioning, and teaching are appropriate only after confirming the order is safe for the client’s condition. Clarifying the order also supports timely diagnostic evaluation and surgical management without introducing avoidable complications.

Question 41

The nurse manager is mediating a grievance brought by the NA about the nurse after the NA was unsuccessful in resolving the conflict. At the mediation session the NA repeatedly states that THE nurse’s delegation is unfair and overloading while the nurse continues to repeat the REASONS for the delegated activities. Which is the nurse manager’s best course of action at this time?

Accepted Answer

Answer reason: The repeated statements from both parties suggest the stated issue (delegation fairness vs rationale) may be masking concerns such as workload distribution, role expectations, or communication style. Facilitating exploration helps the manager uncover root causes and move the discussion toward problem-solving and mutually acceptable agreements. Taking sides would escalate defensiveness, and forcing them to “resolve it themselves” abdicates the manager’s role in a formal grievance process.

Question 42

The client with CRF is placed on a restricted renal diet that includes limiting protein and dairy intake. Alter reviewing a list of allowed, limited, and restricted foods, the client tells the nurse, "I don't like any of the acceptable food choices, and some are against my faith beliefs". Which collaborative action would best meet the client's needs?

Accepted Answer

Answer reason: A registered dietitian is the appropriate interprofessional specialist to create acceptable alternatives within the prescribed renal restrictions and to provide detailed counseling and meal planning. This action directly addresses the client’s stated barriers (taste preferences and faith-based restrictions) using the most qualified resource. Simply “compromising” without dietetics expertise risks violating renal limits, and framing the issue as noncompliance to adjust medications does not resolve the dietary problem driving the conflict.

Question 43

Several nurses are discussing their unhappiness with some residents of an extended care facility placing increased demands on staff. Which statement, if made by one of the nurses, suggests a unit culture characteristic of transformational leadership?

Accepted Answer

Answer reason:  Transformational leadership emphasizes shared governance, staff empowerment, and engaging the team in problem-solving to improve unit culture and outcomes. Inviting the concern to a staff meeting specifically seeks input from multiple stakeholders, supporting participation and collective ownership of solutions. In contrast, merely escalating the issue up the chain of command reflects a more hierarchical approach and does not build staff engagement. Assigning one person to “talk to the residents for us” shifts responsibility without fostering team collaboration and improvement. Using structured team discussion also helps identify system-level fixes rather than isolated complaints.

Question 44

There are multiple theories of management utilized in nursing. Management theories generally fall under one of two distinctly different and opposing schools of thought with regard to the management of people. What are the two current prevailing theories of modern management?

Accepted Answer

Answer reason: Modern management thought is commonly framed as two broad, contrasting schools: an efficiency/productivity focus versus a people/motivation focus. Scientific management (Taylorism) emphasizes task standardization, workflow optimization, and measurable output to improve efficiency. The human relations approach emphasizes interpersonal dynamics, motivation, communication, and job satisfaction as key drivers of performance. Options introducing “theocratic,” “democratic,” or generic “leadership” are not the classic prevailing opposing schools used in nursing management theory overviews.

Question 45

During client care rounds with the multidisciplinary team, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client, in which the physician participating in rounds writes the order. This is an example of?

Accepted Answer

Answer reason: Interprofessional collaboration uses the distinct expertise of multiple disciplines to identify a problem, plan care, and implement needed services to improve outcomes. Here, the nurse identifies a symptom suggestive of dysphagia/aspiration risk, the dietician recommends further evaluation, and the physician facilitates the plan by entering the order—showing coordinated teamwork across roles. This is broader than collaboration with only “ancillary providers” because it includes multiple disciplines working together during rounds. It is also not a risk management consultation; it is routine coordinated care planning to reduce aspiration risk.

Question 46

The nurse discovers a new stage II pressure ulcer on a client’s coccyx area during the bath. What is the most appropriate action for the nurse to take in order to initiate appropriate care for the client?

Accepted Answer

Answer reason: Newly identified pressure injuries require prompt assessment, staging verification, and initiation of an evidence-based prevention/treatment plan using the appropriate interprofessional resources. A wound care nurse is the most direct and appropriate consultant to evaluate the ulcer and recommend dressings, pressure redistribution, and a turning/moisture management plan. Notifying the provider may be needed later, but the immediate nursing action to initiate appropriate care is to obtain specialized wound assessment and guidance. “Code skin” is not a standard emergency response, and family notification is not the first clinical step in managing the new breakdown.

Question 47

During an initial morning assessment, a client appears to be hallucinating; complaining about “bugs on the wall” and “the dog that ran under the bed.” The nurse reorients the client to person, place, and time and the client demonstrates good recall of the information. After the client receives the morning medications, the hallucinations begin again. The nurse notifies the physician that the client’s hallucinations returned shortly after the medications were administered. The physician requests the nurse to call the clinical pharmacist to evaluate the client’s medication list for a possible medication source of the hallucinations. The actions of the nurse resulted in?

Accepted Answer

Answer reason: The key principle is interdisciplinary collaboration to investigate and manage a suspected medication-related adverse effect. The nurse recognized a temporal relationship between medication administration and symptom recurrence, reported the finding to the provider, and facilitated pharmacist review of the regimen to identify causative agents and recommend adjustments. This is consultation within a multidisciplinary team to support further evaluation and treatment planning. It is not delegation, because responsibility for assessment and clinical judgment was not transferred to unlicensed staff, and it is not primarily “medication error prevention” because there is no evidence of an error—rather a potential adverse drug effect.

Question 48

A client is admitted with complaints of general fatigue and episodes of syncope. The client’s spouse states that the client snores loudly at night and often stops breathing for prolonged periods. The nurse assesses the sleeping client and documents heavy snoring with periods of apnea lasting up to 30 seconds. The nurse reports these assessment findings in multidisciplinary client care rounds and the physician requests a consultation with a specialist for evaluation of possible severe sleep apnea. The collaborative client care effort by the multidisciplinary team resulted in?

Accepted Answer

Answer reason: Interdisciplinary collaboration involves sharing assessment data so the team can coordinate referrals, diagnostics, and specialty input. The nurse identified and communicated clinically significant sleep-related breathing findings, and the physician responded by initiating a specialist referral, which is the direct outcome described. A nursing assessment alone cannot establish a medical diagnosis; confirmation requires diagnostic evaluation (e.g., sleep study) and provider interpretation. This scenario is not delegation because no tasks are being assigned to personnel based on scope and competence.

Question 49

A hemodialysis client presents to the dialysis clinic for a regularly scheduled dialysis session. The nurse assesses the client’s dialysis access graft before beginning the treatment. The graft site appears reddened and feels abnormally warm to the touch. The client reports a fever and aching joints for the past two days and a headache starting that morning. The client’s temperature is 101.5F. What is the most appropriate immediate action by the nurse to provide the correct treatment for the client?

Accepted Answer

Answer reason: Fever plus a red, warm dialysis graft strongly suggests an access infection with risk for bacteremia/sepsis and possible need to hold dialysis via that access, obtain cultures, and start antibiotics per provider orders. Continuing dialysis without provider evaluation can worsen systemic infection and also risks contaminating the circuit or using an infected site. The nurse’s priority is timely escalation and coordination of care so the treatment plan can be changed (e.g., alternative access, diagnostic workup, antimicrobial therapy). Options that proceed with dialysis or rely on the client’s subjective “feels well” assessment delay definitive management and are unsafe when infection is suspected.

Question 50

A client scheduled for a colostomy placement asks, "What will my ostomy look like, and how many days will I have it?" The nurse consults which member of the health care team to best answer the client's questions?

Accepted Answer

Answer reason: The ostomy/enterostomal therapy nurse is trained to explain expected stoma appearance, provide preoperative marking, teach pouching/skin care, and set realistic expectations for recovery and duration (temporary vs permanent) based on the surgical plan. This role directly addresses the client’s anatomical and self-management questions and reduces postoperative complications like peristomal skin breakdown. A social worker or case manager can help with resources and discharge planning, but they are not the primary experts in stoma assessment and hands-on ostomy education.

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