comp davis book prioritization

27. The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound. 2. Keep the resident's heels off the surface of the bed. 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake.

**1.Wound debriding formulations are med- ications, and a UAP cannot administer medications. 2.The UAP can position the resident so that pressure is not placed on the resident's heels. 3. The UAP can turn the resident. 4.The UAP can give the resident a protein shake to drink.

11. The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

1. A secondary nursing intervention includes screening for early detection. The bone density evaluation will determine the density of the bone and is diagnostic for osteoporosis. 2. Spinal screening examinations are performed on adolescents to detect scoliosis. This is a secondary nursing intervention, but not to detect osteoporosis. 3. Teaching the client is a primary nursing in- tervention. This is an appropriate interven- tion to help prevent osteoporosis, but it is not a secondary intervention. 4. Discussing risk factors is an appropriate in- tervention, but it is not a secondary nursing intervention.

15. The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? 1. The UAP is not at risk for contracting an illness. 2. The UAP should wear a mask, gown, and gloves. 3. The UAP may skip performing postmortem care. 4. Ask whether the UAP is pregnant before she enters the client's room.

1.The UAP may be at risk of contacting the illness. **2.The UAP should wear appropriate per- sonal protective equipment when provid- ing any type of care. 3.The UAP should not be told to skip perform- ing assigned tasks. 4.The fetus is not affected by anthrax.

14. The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? 1. Instruct her to assist the client with a shower. 2. Ask her to prepare the breakfast meal for the client. 3. Request her to take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

**1.The HH aide's responsibility is to care for the client's personal needs, which includes assisting with a.m. care. 2.The HH aide is not responsible for cooking the client's meals. 3.The HH aide is not responsible for taking the client to appointments. This also pre- sents an insurance problem, because the client would be riding in the HH aide's car. 4.Even in the home, the HH nurse should not delegate teaching.

22. The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. 2. The client diagnosed with pneumonia who has an oral temperature of 100.2°F. 3. The client diagnosed with cystitis who complains of burning on urination. 4. The client diagnosed with pancreatitis who complains of pain that is an 8.

**1.The therapeutic PTT level should be 11/2 to 2 times the control. Most controls average 36 seconds, so the therapeutic levels of heparin would place the control between 54 and 72. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first. 2.A client diagnosed with pneumonia would be expected to have a fever. This client can be seen after the client diagnosed with a DVT. 3.Cystitis is inflammation of the urinary blad-der, and burning on urination is an expected symptom. 4.Pancreatitis is a very painful condition. Pain is a priority but not over the potential for hemorrhage.

12. The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheel- chair. Which priority action should the HH nurse tell the HH aide? 1. Explain how to perform isometric exercises. 2. Instruct her to go to the local emergency room. 3. Tell her to complete an occurrence report. 4. Recommend that she apply an ice pack to the back.

1. Isometric exercises such as weight lifting in- crease muscle mass. The HH nurse should not instruct the HH aide to do this type of exercises. 2.The HH aide may go to the emergency de- partment, but the HH nurse should address the aide's back pain. Many times, the person with back pain does not need to be seen in the emergency room. 3.An occurrence report explaining the situa- tion is important documentation and should be completed. It provides the staff member with the required documentation to begin a workers' compensation case for payment of medical bills. However, the HH nurse on the phone should help decrease the HH aide's pain, not worry about paperwork. **4.The HH aide is in pain, and applying ice to the back will help decrease pain and inflammation. The HH nurse should be concerned about a coworker's pain. Re- member: Ice for acute pain and heat for chronic pain.

3. The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

1. The graduate nurse should handle the situation directly with the UAP first before notifying the charge nurse. 2. Thismayneedtobecompleted,butnotpriorto directly discussing the behavior with the UAP. 3. The graduate nurse must address the insubor- dination with the UAP, not just complete the tasks that are the responsibility of the UAP. **4. The graduate nurse must discuss the in- subordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks.

18. The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the licensed practical nurse (LPN)? 1. The 6-year-old client diagnosed with sickle cell crisis. 2. The 8-year-old client diagnosed with biliary atresia. 3. The 10-year-old client diagnosed with anaphylaxis. 4. The 11-year-old client diagnosed with pneumonia.

1.A client in a crisis should be assigned to the registered nurse (RN). 2.Biliary atresia involves liver failure, involving multiple body systems. This client should be assigned to the RN. 3.Anaphylaxis is an emergency situation. The client should be assigned to the RN. **4.The LPN can administer routine medica- tions and care for clients who have no life-threatening conditions.

25. The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? 1. Apply a sterile dressing to a Stage IV pressure wound. 2. Check the blood glucose level of a resident who is weak and shaky. 3. Document the amount of food the residents ate after a meal. 4. Teach the residents how to play different types of bingo.

1.A nurse, not the UAP, should perform sterile dressing changes. 2. This client is unstable, and a nurse should perform this task. **3. The UAP can check to see the amount of food the residents consumed and docu- ment the information. 4. This is the job of the activity director and volunteers working with the activities depart- ment. Staffing is limited in any nursing area; the UAP should be assigned a nursing task.

13. The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? 1. Tell the HH aide to allow the client to stay in bed until the pain goes away. 2. Instruct the HH aide to get the client up to a chair and give her a bath. 3. Explain to the HH aide the client should get up and take a warm shower. 4. Arrange an appointment for the client to visit her healthcare provider.

1.Allowing the client to stay in bed is inappro- priate because a client with osteoarthritis should be encouraged to move, which will decrease the pain. 2.A bath at the bedside does not require as much movement from the client as getting up and walking to the shower. This is not an appro- priate action for a client with osteoarthritis. **3.Movement and warm or hot water will help decrease the pain; the worst thing the client can do is not to move. The HH aide should encourage the client to get up and take a warm shower or bath. 4.Osteoarthritis is a chronic condition, and the HCP could not do anything to keep the client from "hurting all over."

4. The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

1.This should not be implemented until verifi- cation of the allegation is complete, and the shift manager has discussed the situation with the UAP. **2. The shift manager should have objective data prior to confronting the UAP about the allegation of falsifying vital signs; therefore, the shift manager should take the client's vital signs and compare them with the UAP's results before taking any other action. 3. The shift manager should not confront the UAP until objective data are obtained to sup- port the allegation. 4. Written documentation should be the last action when resolving staff issues.

23. The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's abdominal dressing for drainage. 3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

3, 4, and 5 are correct. 1. Teaching is the responsibility of the nurse and cannot be delegated to a UAP. 2. The word "check" indicates a step in the assessment process, and the nurse cannot delegate assessing to a UAP. 3. The client is 2 days postoperative and vital signs should be stable, so the UAP can take vital signs. The nurse must make sure the UAP knows when to immediately notify him/her of vital signs not within the guidelines the nurse provides to the UAP. 4. This action does not require judgment on the part of the UAP: it does not re- quire assessing, teaching, or evaluating. This can be delegated to the UAP. 5. A client who is 2 days postoperative should be ambulating frequently. The UAP can perform this task.

9. The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.

1.The UAP can apply sequential compression devices to the client on strict bed rest. 2.The UAP can assist with a portable STAT chest x-ray, as long as it is not a female UAP who is pregnant. **3.The client will need to be pre-medicated for a wound debridement; therefore, this task cannot be delegated to the UAP. 4.The UAP can obtain intake and output for clients.

10. The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? 1. Systems that make it difficult for the nurses to do their job. 2. How unhappy the nurses are with their current pay scale. 3. Collective bargaining activity at a nearby hospital. 4. The number of medication errors committed by an individual nurse.

**1.A quality improvement project looks at the way tasks are performed and attempts to see whether the system can be im- proved. A medication delivery system in which it takes a long time for the nurse to receive a STAT or "now" medication is an example of a system that needs im- provement, and should be addressed by a quality improvement committee. 2.Financial reimbursement of the staff is a management issue, not a quality improve- ment issue. 3.Collective bargaining is an administrative issue, not a quality improvement issue. 4.The number of medication errors committed by a nurse is a management-to-nurse issue and does not involve a systems issue, unless several nurses have committed the same error because the system is not functioning properly.

21. The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? 1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. 2. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau's sign.

**1.The Glasgow Coma Scale ranges from 0 to 15, with 15 indicating the client's neurological status is intact. A Glasgow Coma Scale score of 13 indicates the client is stable and would be the most appropriate client to assign to the graduate nurse. 2.This client's K+ level is low, and the client is at risk for developing cardiac dysrhythmias; therefore, the client should be assigned to a more experienced nurse. 3.This client has a low blood pressure and evidence of tachycardia and could possibly go into an Addisonian crisis, which is a poten- tially life-threatening condition. A more experienced nurse should be assigned to this client. 4.A positive Trousseau sign indicates the client is hypocalcemic and is experiencing a com- plication of the surgery; therefore, this client should be assigned to a more experienced nurse.

30. The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? 1. Have another employee drive the clients home. 2. Notify the public health department immediately. 3. Send the clients to the emergency department. 4. Obtain stool specimens from the clients.

1.The employee health nurse should keep the clients at the clinic or send them to the emergency department. The clients should be kept together until the cause of their illnesses is determined. If it is determined that the clients are stable and not contagious, they should be driven home. 2.The employee health nurse should be aware that six clients with the same signs/ symptoms indicate a potential deliberate or accidental dispersal of toxic or infectious agents. The nurse must notify the public health department so that an investigation of the cause can be instituted and appropriate action to contain the cause can be taken. 3.As long as the clients are stable, the nurse should keep the clients in the employee health clinic. These clients should not be exposed to other clients and emergency department staff. If the clients must be transferred, decontamination procedures may need to be instituted. 4.The client may need to provide stool specimens, but this would be done at the emergency department. Employee health clinics

20. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The client who had surgery for an inguinal hernia and who is being prepared for discharge. 2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. 3. The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. 4. The client who has end-stage renal disease and who has had an arteriovenous fistula created.

**1. The most experienced nurse should be assigned to the client who requires teach- ing and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day. 2. A routine preoperative client does not require the most experienced nurse. 3. Any nurse can administer and monitor blood transfusion to the client. 4. Although the creation of an arteriovenous fistula requires assessment and teaching on the part of the most experienced nurse, this client is not being discharged home at this time.

8. Which situation would prompt the healthcare team to utilize the client's advance directive when needing to make decisions for the client? 1. The client with a head injury who is exhibiting decerebrate posturing. 2. The client with a C-6 spinal cord injury (SCI) who is on a ventilator. 3. The client in chronic renal disease who is being placed on dialysis. 4. The client diagnosed with terminal cancer who is mentally retarded.

**1.The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a termi- nal, persistent vegetative state, irreversible coma, or as specified in the advance direc- tive. A client who is exhibiting decerebrate posturing is unconscious and unable to make decisions. 2. The client on a ventilator has not lost the abil- ity to make healthcare decisions. The nurse can communicate by asking the client to blink his or her eyes to yes/no questions. 3.The client receiving dialysis is alert and does not lose the ability to make decisions; there- fore, the advance directive should not be consulted to make decisions for the client. 4.Mental retardation does not mean the client cannot make decisions for him- or herself un- less the client has a legal guardian who has a durable power of attorney for healthcare. If he client has a legal guardian, then the client cannot complete an advance directive.

29. The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first? 1. Determine whether the client has grab bars in the bathroom. 2. Encourage the client to take a shower instead of a bath. 3. Initiate a referral to a physical therapist for the client. 4. Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

**1.The first intervention is for the nurse to ensure the client is safe in the home. Assessing for grab bars in the bathroom is addressing the safety of the client. 2.Taking a shower in a stall shower may be safer than getting in and out of a bathtub, but the nurse should first determine whether the client has grab bars and safety equipment even when taking a shower. 3.According to the NCLEX-RN® test blue- print for management of care, the nurse must be knowledgeable of referrals. The physical therapist is able to help the client with trans- ferring, ambulation, and other lower extrem- ity difficulties and is an appropriate intervention, but it is not the nurse's first intervention. Safety is priority. 4.NSAIDs are used to decrease the pain of osteoarthritis, but this intervention will not address safety issues for the client getting into and out of the bathtub.

5. The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider.

**1.The nurse should first assess the client prior to taking any other action to deter- mine if the client is experiencing any untoward reaction. 2.An incident report must be completed by the nurse but not prior to taking care of the client. 3. The nurse should administer the correct med- ication but not prior to assessing the client. 4.The client's HCP must be notified, but the nurse should be able to provide the HCP with pertinent client information, so this is not the first intervention.

26. The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? 1. Ask the charge nurse to teach all the other UAPs. 2. Encourage the nurse to continue to work with the UAP. 3. Tell the charge nurse to discuss this in a private area. 4. Give the UAP a better explanation of the procedure.

1. The charge nurse is not the nurse educator but is responsible for the UAPs working under him or her. This is adding additional duties to the charge nurse. **2. The director of nurses should encourage responsible behavior on the part of all staff. The charge nurse is performing a part of the responsibility of the charge nurse and should be encouraged to work with the UAP. 3.Because this is not a private conversation about a client, there is no reason for the charge nurse to be told to go to a private area. The charge nurse is not reprimanding the UAP. 4.The director of nurses should not interfere with a "better explanation." This could in- timidate the charge nurse and make it diffi- cult for the charge nurse to perform his or her duties.

17. The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualified. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

1. The clients would not understand the impor- tance of the specific tasks. Clients will tell the nurse whether the UAP is pleasant when in the room but not whether the delegated tasks have been completed. 2. The nurse retains responsibility for the dele- gated tasks. The charge nurse may be able to tell the nurse that the UAP has been checked off as being competent to perform the care but would not know whether the care was actually provided. **3. The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care. 4. The nurse would not have time to complete his or her own work if the nurse watched the UAP perform all of the UAP's work.

2. The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

1. The nurse should stop the behavior from occurring in a public place. The charge nurse can discuss the issue with the UAPs and deter- mine whether the manager should be notified. **2. The first action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs' behavior in public. 3.The second action is to have the UAPs go to a private area before resuming the conversation. 4.The charge nurse may need to mediate the disagreement; this would be the third step.

6. The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

1. The serum blood glucose level requires a venipuncture, which is not within the scope of the UAP's expertise. The laboratory techni- cian would be responsible for obtaining a venipuncture. 2. This is a sterile dressing change and requires assessing the insertion site for infection; there- fore, this would not be the most appropriate task to assign to the LPN. 3. The nurse should ask the UAP to bathe the client and change bed linens because this is a task the UAP can perform. The LPN could be assigned higher-level tasks. **4. The UAP can add up the urine output for the 12-hour shift; however, the nurse is re- sponsible for evaluating whether the urine output is what is expected for the client.

7. Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

1.The client on the ventilator is unstable; there- fore, the nurse should not delegate any tasks to the UAP. **2.The UAP can take specimens to the labo- ratory; these are not medications and they are not vital to the client. 3.The client in an Addisonian crisis is unstable; therefore, the nurse should not delegate any tasks to the UAP. 4.The UAP cannot assist the HCP with an inva- sive procedure at the bedside.

24. The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? 1. The nurse who has the most vacation time. 2. The nurse who requested to be off. 3. The nurse who has the least experience on the unit. 4. The nurse who has called in sick the previous 2 days.

1.Staff members will not stay if forced to always use their paid time off for the hospi- tal's convenience. **2.This nurse wants to take time off. There- fore, it is the best option to let the nurse desiring to be off from work to take time off if all other situations are equal. 3.The nurse will not gain experience if always requested not to come to work, and presum- ably this nurse would not have benefit time to pay for the time out of work. 4.This nurse could be allowed to stay home only if the nurse is still ill.

16. The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers? 1. No information can be released to the mortuary service. 2. The nurse should tell the funeral home the client's diagnosis. 3. Ask the family for permission to talk with the mortician. 4. Refer the funeral home to the HCP for information.

1.The mortuary service is considered part of the healthcare team in this case. The person- nel in the funeral home should be made aware of the client's diagnosis. **2.The mortuary service is considered part of the healthcare team. In this case, the personnel in the funeral home should be made aware of the client's diagnosis. 3.The nurse does not need to ask the family for permission to protect the funeral home workers. 4.The nurse, not the HCP, releases the body to the funeral home.

1. The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

1.The new graduate must work under this charge nurse; confronting the nurse would not resolve the issue because the nurse can choose to ignore the new graduate. Someone in authority over the charge nurse must ad- dress this situation with the nurse. **2.The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation. 3.The new graduate is bound by the nursing practice acts to report potentially unsafe be- havior regardless of the position the nurse holds. 4.The nurse educator would not be in a position of authority over the charge nurse.

28. The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? 1. Place a Posey vest restraint on the client. 2. Move the client to a room near the station. 3. Ask the HCP for an antipsychotic medication. 4. Raise all four side rails on the client's bed.

1.The nurse should implement the least restrictive measures to ensure client safety. Restraining a client is one of the last measures implemented. **2.Moving the client near the nursing station where the staff can closely observe the client is one of the first measures in most fall prevention policies. 3.This is considered medical restraints and is one of the last measures taken to prevent falls. 4.Four side rails are considered a restraint. Re- search has shown that having four side rails up does not prevent falls and only gives the client farther to fall when the client climbs over the rails before falling to the floor.

19. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. 2. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. 3. The client with renal calculi who is complaining of severe flank pain and has hematuria. 4. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia.

1.The nurse would expect the client with DIC to be oozing blood; therefore, the nurse should not need to assess this client first. 2.The nurse would expect the client with BPH to have urinary signs and symptoms such as terminal dribbling, so the nurse should not need to assess this client first. **3.The nurse would not expect the client with renal calculi to have blood in the urine (hematuria) and the pain should not be severe; therefore, this client should be assessed to determine if the client is having complications. 4.The nurse would expect the client with Addi- son's disease to have a bronze pigmentation and hypoglycemia; therefore, the nurse should not need to assess this client first.