L&M H Double Checked
The nurse is reviewing the lab results on 4 clients on the medical unit. In addition to standard precautions, the client with which finding should also be placed on airborne precautions?
Culture of a leg ulcer reveals pseudomonas aeruginosa
The nurse is inserting an indwelling catheter for a client experiencing urinary retention when a code blue is called for another client on the who unit who became unresponsive. Which action should the nurse take?
Finish the procedure
The charge nurse on a surgical unit is assessing the morning lab work on four clients. which client's lab finding should be reported to the HCP immediately'?
An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL and BUN of 84 mg/dL
When making assignments for the day, which information provided during the change of shift report is most important for the charge nurse to consider?
An elderly female client who refuses to be cared for by a male nurse
The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for developing osteomyelitis?
An older adult with osteoporosis who is bedfast following a compression fracture of the vertebrae.
The RN is gathering supplies to assist HCP with thoracentesis at the bedside when the ED nurse calls in report on a client with unstable angina. A PN and UAP are able to assist the RN. How should the RN assign the necessary tasks?
Assign PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for the new client
A home health aid caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. What should the nurse instruct to do?
Assist the client to drink warm prune juice
Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion?
Ceftriaxone 5% Dextrose in Water prescribed for pneumonia.
The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?
A 10 year old child who is receiving chemotherapy and the infusion pump is beeping
Which older client should the charge nurse assign to the most experienced nurse?
A 72-yr old with type 1 diabetes mellitus who is newly diagnosed and scheduled for discharged today
The nurse is assigned to care for four clients. After receiving the change of shift report, which client should the nurse assess first?
A client with diabetes and a history of coronary artery disease who is complaining of increased shortness of breath.
Which situation on an acute care inpatient surgical nursing unit requires intervention by the nurse-manager?
A unit clerk receives a verbal telephone prescription from an attending healthcare provider.
The nurse calls the surgeon to report that a male client who has transitioned from a PCA to PO analgesic one hour ago is now complaining in a loud voice and asking for the PCA pump. The nurse explains that the client's behavior is disturbing his roommate. The client's BP has increased from 120/72 to 150/98. Which question is best to include in the recommendation component of the SBAR report the the surgeon? A. Could the behavior be a manifestation of drug seeking? B. Can the client be transferred to a private room? C. Can the PCA be initiated and prescribed for an additional 12 hours?
A. Could the behavior be a manifestation of drug seeking? Ans: C. Can the PCA pump be initiated and prescribed for an additional 12 hours????
The nurse manger observes that the staff nurse has used wrist restraints to help secure an elderly female to her wheel chair. What is the priority action by the nurse manager?
Advise the nurse to remove the restraints from the clients wrists
It is most important to assign a client to a registered nurse rather than a practical nurse?
After ambulating a postoperative client grimaces and reports incisional pain at a 9 on a ten-point pain scale.
The nurse who is working on a post-surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first?
An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100ml chest tube drainage.
A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. the client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
Ask the family to identify a specific spokesperson
A nationally known management consultant, whose consulting fee is very high, is scheduled to speak at a day-long hospital education conference. The head nurse wants the information presented at the educational program to be disseminated among the staff. Which plan will be most useful in achieving this goal?
Ask two staff members to attend and report what they learned to the unit's staff
One hour after the nurse administers an analgesic, the UAP reports the client refuses to turn in bed because of continued pain. Which action should the nurse take?
Asses the client's current pain level and response to the analgesic
Two clients in the ICU are assigned to an oncoming nurse at shift change. One client has pneumonia and is being mechanically ventilated and the other had a thoracotomy yesterday is is currently complaining of incisional discomfort. Which action should the nurse take next?
Assess LOC and VS for both
An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are:temperature 100° F (37.8° C), blood pressure 98/50 mmHg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
Assess the amount of wound drainage daily
A new female employee reports to the charge nurse that she has developed a rash on her hands and arms. What action is most important for the nurse to take?
Assess the employee for systemic allergic responses.
when caring for an older adult with septic shock which intervention is most important for the nurse to include in this clients plan of care?
B. assess warmth of extremities
After receiving a change of shit report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?
Begin initial sterile wound care for surgical clients.
The nurse watches an unlicensed assistive personnel (UAP) bring soap, washcloths and towels, and a basin into the room of a male client who had a suprapubic catheter inserted earlier that day. What action should the nurse implement?
C. Tell the UAP that the nurse will perform the client's catheter care after the UAP assists with his personal care. RationaleSuprapubic catheters are inserted surgically, so initial catheter care involves removal of the dressing and inspection of the surgical site, which should be performed by the nurse (C) rather than the UAP (A and B). If the catheter will be in place after discharge, the nurse should teach the client how to care for the catheter (D) during discharge instructions.
The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit
Conduct a closer examination of staff nurse's distribution of pain medication from evening shift
An older woman with a long history of hypertension is transferred from a long-term care facility to the hospital intensive care unit because of an exacerbation of heart failure (HF). She has a signed and witnessed "do not resuscitate" from in her record. Which action should the nurse take?
Confirm current resuscitation wishes with client and family.
The practical nurse (PN) reports to the charge nurse that the transparent dressing covering a single lumen central venous catheter inserted in the subclavian vein of a client has come loose and the insertion site is inflamed. Which action should the charge nurse implement?
Confirm the findings of the PN while securing the transparent dressing and notify the healthcare provider.
An older male client who lives alone has a history of heart failure and is admitted to the hospital after passing out while walking to the mailbox. The nurse notes multiple bruises at various stages of healing.The client is being treated with a cardiac glycoside, diuretic and restricted sodium diet. Which intervention is most important for the nurse to include in the clients plan of care?
Continuous electrocardiogram monitoring.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction. RationaleChecking a client for fecal impaction (D) may cause a vagal response, leading to severe bradycardia. This action should be performed by the nurse, rather than a UAP, so the charge nurse should immediately change this assignment. A graduate nurse can obtain and administer blood products (A), but may need supervision with the administration. (B and C) do not require immediate follow up by the charge nurse.
The nurse observes a PN placing a client on the right side with left leg bent in prep for lumbar puncture. Which action should the RN take?
Demonstrate to the PN how to position the client more effectively for the procedure
The nurse is caring for a group of clients on a surgical unit. Which action should the nurse implement first?
Determine if the client scheduled for surgery is prepared to go to the OR.
The charge nurse observes a newly employed nurse begin to administer a liquid medication via a client's gastrostomy feeding tube system as seen in the picture. What action should the charge nurse take?
Direct the nurse to stop the medication administration.
To help prevent litigation by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
Discuss how to handle complains from clients and/or their families
The nurse is planning care for a client who is experiencing acute pain. Which intervention can be implemented by the unlicensed assistive personnel (UAP) in providing personal care for the client?
Distraction
The nurse is reviewing records of clients with diabetes in a long-term care facility, The nurse notes that the pre-prandial blood glucose values, obtained during routine glucometer checks in the past 2 days, are consistently 50 to 60 mg/dL higher than those recorded in the previous 2 weeks. What action should the nurse take first?
Evaluate calibration of glucometers in use per manufacturer guidelines
A male client who recently learned that he has Huntington's disease tells the nurse that he does not want his daughter to know about the disease because she may someday want to have a child of her own. Which intervention should the nurse implement?
Explain that his daughter has a right to know of potential health problems.
An experienced practical nurse (PN) and an unlicensed assistive personnal are working together to assist neurologically compromised clients at mealtime. Whish task is best for the PN to perform?
Feed a quadriplegic client who has difficulty shewing and swallowing
While the nurse is assisting the healthcare provider with a sterile bedside procedure, a Code Blue is called for another client on the unit who is experiencing a cardiac arrest. Which action should the nurse take?
Finish the Procedure
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. What action is most important for the nurse to take?
Give detailed report to accepting nurse
The nurse notes the toes of a clients casted leg are cold and turning blue. The HCP is notified by phone three times, but four hours after the first notification the HCP has not come to see the client who is now complaining of severe pain. Which action is most important for the nurse to take?
Have the nursing supervisor report the situation immediately to the medical chief of staff
A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
How many departments can use this equipment?
A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family presents that clients sign power of attorney and a home medication list. When reporting to the healthcare provider using SBAR communication, which information should the nurse provide first
Increasing confusion of the client
A client with severe bilateral crush injuries to the lower extremities is informed by the HCP that amputation is the only option for the client to live. The client request no life saving measure to be taken. The HCP refuses to write the DNR order. Which action should the nurse take?
Initiate a review of the situation by the hospital's ethics committee
The UAP reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?
Instruct the UAP to weight the client using the bed scale
To facilitate the success of a new fall prevention program, which action should the nurse manager implement?
Involve the staff in developing interventions for the program
An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which nurse should be responsible in coordinating the progression or this client's care through rehabilitation and discharge?
Nurse case manager
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
Keep mucous membranes moist
An older female client who was recently widowed has become increasing confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed health plan. Which information is best for the nurse to provide the family?
Managed care providers have mandatory pre certification requirements for hospitalization
The nurse hears a newly employed unlicensed assistive personnel (UAP) who is working in a long term care facility calling the adult residents "honey" and "dearie". What is the best action to take?
Meet with the UAP to discuss respectful client care strategies.
A client with tachycardia and hypotension presents to the emergency department reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
Monitor for impending signs of shock
The nurse is caring for an older adult who was admitted with a Urinary tract infection and is now exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative care goals should the nurse include in the plan of care? (Select all that apply)
Negative urine cultureBody temperature within normal limitsReduce white blood cell count
The nursing supervisor sends an unlicensed assistive personnel (UAP) to a medical unit to replace an absent UAP. When delegating the task of obtaining client's blood sugar levels using a glucometer, which action is most important for the nurse to implement?
Observe the UAP obtain a finger stick glucose level using the glucometer
An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?
Obtain a do not resuscitate prescription
Aspirin 81 mg at 0900 daily is prescribed for an older client. At 0800 the client asks for something for low back pain, but does not have a PRN order for analgesics prescribed. Which action is best for the nurse to take?
Obtain a prescription for a PRN analgesic
A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which tasks should the nurse to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Offer high caloric foods such as milk and ice cream. Maintain a clean and pleasant environment during meals. Assist the client with eating small frequent high calorie meals. Set up the food and drink containers within easy reach.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
Place an isolation cart outside of the room to initiate droplet precautions.
In reviewing the admission records of a 16-year-old male client with acute glomerulonephritis, the nurse notes that the healthcare provider has given no instructions regarding measurements of intake. Which intervention should the nurse implement?
Start the intake and output record and teach the client and family how to record fluids
The charge nurse notices that a respiratory therapist who has been cross-trained to work as a phlebotomist and UAP seems to be avoiding HIV positive clients. What action should the nurse take?
Provide the employee with feedback about the observed behavior
A healthcare provider notifies the nurse that new prescriptions have been written for a client. Which is the 1st action the nurse should implement?
Read all of the new prescriptions for the client written by the provider
The charge nurse in an emergency center is planning client care assignment for the staff. Which action may be safely delegated to the practical nurse (PN)?
Reinforce client teaching for discharge to home
In planning care for a group of clients, which task should the nurse delegate to the UAP?
Reinforce teaching provided by the nurse about using the call bell
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?
Remain nonjudgmental and assure the client of confidentiality
A fire is reported in the kitchen on the first floor of a three floor community hospital and the operator notifies the charge nurse of the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives. Choice C Reason: Shutting all doors to client rooms and telling everyone to stay in their rooms until the fire department arrives is the best intervention, as it follows the RACE protocol, which means containing the fire by closing doors and windows, and extinguishing it if possible with a fire extinguisher. This intervention also helps protect the clients and staff from smoke inhalation and fire spread, and allows the fire department to access and control the fire.
The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse? (PN)
Remove Peripheral Intravenous (PIV) Catheter
The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What is the best initial action for the charge nurse to take.
Remove the glass of water and speak to the UAP.
The nurse assigns an unlicensed assistive personnel (UAP) to apply sequential compression devices to a client. Which instruction should the nurse include when assigning this task to the (UAP)?
Report any changes in color in the client's feet or legs
Contact precautions are being implemented for a client with cellulitis of the right foot. The nurse observes the UAP eating candy given to her by the client's family in the client's room. What action should the nurse take?
Report the possibility of cross contamination to infection control
Because of budget cutbacks, a policy was established which mandates that when the census is low, nurses will be sent home. For the third time in two weeks, a nurse who has been employed at the hospital for three months is sent home immediately after arriving to work. The nurse is obviously upset and begins to cry when told to go home. Which action should the charge nurse take
Take the nurse to private place and listen to the nurse's concerns
In planning care on the nursing unit, which task is best to assign to the nurse (RN), rather than a practical nurse (PN)?
Teach a client with diabetes to inject insulin.
The charge nurse assigns an experienced PN to care for a client who needs a complex dressing change. The female PN who seems anxious with difficult assignments, tells the charge nurse that she does not feel competent to perform the procedure. Which is the best way for the charge nurse to handle this situation?
Tell the PN that assistance is available if needed but she will be responsible for the patient's care.
After reviewing the morning laboratory findings for four clients, which client should the nurse follow-up with first?
The BNP assay for a client with shortness of breath after a MI increases to 1000 pg/mL.
A nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for an acutely ill client requiring immediate bedside insertion of a chest tube. Which assignment is best use of each persons skills?
The UAP obtains oxygen saturation level while the RN reports findings to the healthcare provider
The nurse calls the surgeon about a male client who is having abdominal pain after a bowel resection. He received hydromorphone 2 hours ago and is not requesting additional pain medication. VS include temp 97.8, HR 112 bpm, RR 24, BP 98/62, which is lower than an hour ago. Client has hx of chronic A fib and take clopidogrel, which was discontinued the day before surgery. The nurse recommends that the surgeon see the client immediately for evaluation. What information makes the report complete?
The abdomen is rigid, tender to the touch and distended.
The charge nurse, along with one nurse, two practical nurses (PN) , a unit secretary, and two unlicensed assistive personnel (UP), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the nurse?
The admission assessment of a client diagnosed with bacterial pneumonia
While eating breakfast, a client admitted with syncope and a 2-month history of vertigo complains of dizziness. Using the standard communication tool SBAR (Situation, Background, Assessment, Recommendation), which statement is best for the nurse to provide the healthcare provider about the client's background?
The client's significant history includes atrial fibrillation and hypoglycemia.
When the nurse manager is calculating the number of full time equivalents that are needed to staff a unit of an acute care hospital, which factor is most important in determining this calculation
The clients acuity level
The nurse is observing the staff provide care to a client with AIDS who was admitted yesterday with pneumocystis pneumonia. which staff scenario requires interventions by the nurse?
UAP wearing mask to take patients blood pressure
The nurse is caring for a group of clients with the help of an experienced unlicensed assistive personnel UAP . Several specimens need to be collected and sent to the lab. Which specimen collection can the nurse delegate to the UAP? (SATA)
Urine from indwelling catheter. Fecal drainage sample.
An unlicensed assistive personnel (UAP) is stuck in the palm of the hand by a needle that is found in the bed linen of a client diagnosed with Hepatitis B. Which action should the charge nurse instruct the UAP to do first?
Wash hands with soap and water
An experienced PN is hired to work on the surgical unit of a tertiary hospital . the first day she is working on the unit, the PN tells the nurse that she has excellent wound care skills. It is a busy day and a post op client needs to have a sterile dressing change. Which action is best for the charge nurse to take?
Watch the PN perform sterile wound care to validate her skill level
In assigning client care to a RN and a PN, it is most important to assign which client to the RN? The client who
is exhibiting signs of Addison's crisis after corticosteroids were discontinued
