Leadership & Management NCLEX Questions

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new onset atrial fibrillation

2. A client with Cushing syndrome who needs intermittent urinary catheterization Routine procedures such as urinary catheterization fall well within the LPN scope of practice. The other clients are in crisis and unstable, requiring acute care by an RN.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1. The acuity level of the clients 5. Client needs and workers' needs and abilities These are guidelines that the nurse should use when delegating and planning assignments. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

A nurse cares for a client on life support who has been declared brain dead. Which intervention is appropriate at this time? 1. Ask the family members about their plans for the funeral service 2. Call the local organ procurement services representative 3. Discontinue nursing care and provide postmortem care 4. Remove life support as requested by the spouse and family

2. Call the local organ procurement services representative Local organ procurement services (OPS) are notified for every client death, per hospital protocol. If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation. Cardiac support and respiratory support continue as organ donation is discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donation due to physiological reasons or the client/family does not consent.

Multiple clients arrive at the emergency department. Which client should the triage nurse prioritize for the health care provider to see first? 1. Client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm 2. Client with dementia arriving with new onset restlessness and confusion 3. Client with epilepsy who had a seizure earlier but is now alert and oriented 4. Client with newly deformed forearm with normal circulation and sensation, pain rated 8/10

2. Client with dementia arriving with new onset restlessness and confusion Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline. The sudden onset of a new behavior may indicate delirium caused by an infection or another serious etiology and is therefore considered a priority.

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28 year old with infective endocarditis and heart rate of 105/min 2. 45 year old with acute pancreatitis and sinus tachycardia of 120/min 3. 65 year old with tachycardia of 110/min after liver biopsy 4. 74 year old on diltiazem drip with atrial fibrillation and heart rate of 115/min

3. 65 year old with tachycardia of 110/min after liver biopsy The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65 year old client should be assessed first

The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. Personally go and auscultate the client's lungs

4. Personally go and auscultate the client's lungs When a registered nurse (RN) receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be used to decide if an urgent need exists and a change in the nursing plan of care is needed.

A young Spanish speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitated client privacy under HIPAA 5. Teach about one intervention at a time and in the order it will occur

2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 5. Teach about one intervention at a time and in the order it will occur Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive. The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms 2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over clients who are confined to bed 5. Relocate ambulatory clients from the hallways back into their rooms

2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over clients who are confined to bed In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3. A client who requires urine specimen collections The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experiencing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim experiencing altered level of consciousness

3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

Which issue would a unit quality improvement committee address? 1. A 10% decrease in client satisfaction in the registration process 2. A nurse who made 3 medication errors in the past quarter 3. An increase in catheter-associate urinary tract infections 4. Staff perception of hospital laboratory personnel incivility

3. An increase in catheter-associate urinary tract infections Issues addressed by a unit quality improvement committee should be related to standards and clinical factors involving the specific unit.

The nurse employed in a long term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3. Middle aged client with vaginal itching and white, curdlike discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face

4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (e.g., rescue position, head of bed elevation, intubation).

The nurse receives report on 4 clients. Which client should be seen first? 1. 10 month old with audible congestion and mucus producing cough 2. 10 year old with an active nose bleed who is applying pressure 3. 12 year old with urinary frequency and burning, and fever 4. 15 year old with painful right hip, fever, and limited range of motion

4. 15 year old with painful right hip, fever, and limited range of motion This client is exhibiting localized (eg pain, limited ROM) and systemic infection symptoms (eg fever) which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection. A septic hip is considered a surgical emergency.

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. This client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh really? I will discuss this situation with your son." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends who can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation.

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? 1. Administer water enema to the 2 year old with intussusception who has severe abdominal pain 2. Call the HCP about the 4 year old with leukemia who has a low grade fever 3. Measure head circumference of the 3 month old with ventriculoperitoneal shunt placement 4. Suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding

4. Suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress.

A Spanish speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which is the most appropriate action by the nurse? 1. Act as a witness for the informed consent process 2. Provide additional information about what the client can expect 3. Report the surgeon to the ethics board for using an inappropriate consent process 4. Talk to the surgeon privately about using a trained Spanish language medical interpreter

4. Talk to the surgeon privately about using a trained Spanish language medical interpreter The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. To protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and a family member is the only one available to fill this role.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? 1. Reassess the client 2. Conduct a staff meeting to describe the fall 3. Contact the nursing supervisor to update information regarding the fall 4. Document in the nurse's notes that an occurrence report was completed

1. Reassess the client After a client's fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An occurrence report is a problem solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the occurrence, the supervisor will contact the nurse if status update is necessary.

Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8 year old client who uses corticosteroid inhaler and has white patches on the tongue 2. 50 year old client who developed a smooth, red, pinpoint rash after taking sulfa 3. 60 year old client with pain and crusted blisters along the back 4. 70 year old client who has erythema with a small pustule at the hair follicle

2. 50 year old client who developed a smooth, red, pinpoint rash after taking sulfa Petechiae can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptoms takes priority over a more localized dermatological presentation. Option 3 indicates shingles. However it is deemed a second priority as it is a localized issue.

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 28 year old female client who fell on ice yesterday and has low back pain and spasm 2. 42 year old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights 3. 65 year old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F 4. 70 year old male client with peripheral vascular disease who has acute onset abdominal pain radiating to the low back

4. 70 year old male client with peripheral vascular disease who has acute onset abdominal pain radiating to the low back An abdominal aortic aneurysm (AAA) is a blood filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. AAA dissection or rupture may manifest as acute onset abdominal pain radiating to the back an dis typically associated with symptoms of hemorrhagic shock. This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold

1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. However, the client is not radioactive or infectious and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature" 2. "You will need to find a witness son your own" 3. "Whoever is available at the time will sign as a witness for you" 4. "I will call the nursing supervisor to seek assistance regarding your request"

4. "I will call the nursing supervisor to seek assistance regarding your request" Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The charge nurse in the medical surgical unit is evaluating client safety. Which actions by UAP would require the nurse to intervene? Select all that apply. 1. 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 2. 1 UAP using a gait belt to transfer a partial weight bearing client from the bed to a chair 3. 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours 4. 2 UAPs using the log rolling technique to move a client with a cervical collar 5. 3 UAPs using a draw sheet to move a client who weights 220lb (100 kg) up in bed

1. 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 4. 2 UAPs using the log rolling technique to move a client with a cervical collar Repositioning and transferring clients can be delegated to UAP when it is deemed safe and appropriate. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving. The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction.

The nurse calls the primary health care provider (PHCP) regarding a new mediation prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor 2. Administer the dose prescribed 3. Hold the medication until the PHCP can be contacted 4. Administer the recommended dose until the PHCP can be located

1. Contact the nursing supervisor If the PHCP writes a prescription that requires clarification, the nurse's responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was writing after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the HCP that the client needs a do not resuscitated (DNR) order

1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision Advance care planning is a process that includes: -Considering treatments that may be needed in the future -Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions -Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record -Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future -Ensuring that the health care proxy has information and documentation to support that role if this person needs to make decisions for the client

The HCP remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager 2. Tell the HCP to stop the comments 3. Walk away and say nothing 4. Write up an incident report

2. Tell the HCP to stop the comments Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stope. IF that is not effective, additional action should be taken.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure 2. Ask the EMS team to sign the informed consent 3. Transport the victim to the operating room for surgery 4. Call the police to identify the client and locate the family

3. Transport the victim to the operating room for surgery In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent.

The nurse is working on a busy medical surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

1. A 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and Celecoxib, a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing would be warranted.

The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and pulseless. The nurse calls the HCP at 2 AM, and the HCP begins to yell at the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is the best response by the nurse? 1. "I am concerned that this client may lose a leg unless something is done immediately." 2. "I am required to report all postoperative complications to the provider on call." 3. "It is my job to report critical findings, just like it is your job to come see my client right now." 4. "Yelling is unprofessional. I will need to file a report with my supervisor once the client is stable."

1. "I am concerned that this client may lose a leg unless something is done immediately." The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for clients. In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's needs, especially in situations that may result in client injury.

A RN, LPN, and UAP are caring for a client who is 1 day postoperative gastric bypass surgery. Which pain management related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1. Administering oral pain medication 4. Monitoring pain level using a numeric scale The RN is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain, performing initial client and caregiver teaching, and evaluating the effectiveness of the care plan (Option 2 and 5). The RN should delegate vital sign measurement to the UAP. Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change

1. A client who fell and hit the head but refuses to go to the emergency department 3. A client who needs pre-filled insulin syringes 5. A client with a stage 3 pressure injury in need of a dressing change In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed.

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply. 1. Assist the registered nurse with ambulating a client 1 day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery

1. Assist the registered nurse with ambulating a client 1 day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery UAP may perform routine tasks for stable clients under the direction of the RN. Tasks related to the nursing process (eg assessment, planning, evaluation) require trained knowledge, critical thinking, and individualized application by the RN and cannot be delegated.

The nurse in the emergency department receives 4 clients. Which client should the nurse see first? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low grade fever, barking cough, and runny nose who has mild retractions

1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting, hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ration (INR) of 1.3 2. Client with chronic bronchitis who has a hematocrit of 56% and hemoglobin of 19 g/dL 3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL

1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ration (INR) of 1.3 The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the HCP as the client is at increased risk for a stroke and dose adjustment is needed.

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing Removing a dressing that has been on the client's skin is not a sterile procedure. The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed.

Which identifies accurate nursing documentation notation(s)? Select all that apply. 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. The client appears to become anxious when it is time for respiratory treatments 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12 year old with right lower quadrant abdominal pain that started in the periumbilical region 2. 14 year old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16 year old with sickle cell disease who has excruciating generalized body pain 4. 34 year old with sudden onset, right sided flank pain radiating to the right groin.

2. 14 year old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left Testicular torsion is an emergency condition in which blood flow to the testis has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority.

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate? 1. 3 year old with a temperature of 102.4 F (39.1 C) who had a seizure at home 30 minutes ago and is very irritable 2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale 3. 32 year old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best 4. 72 year old prescribe antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale A fractured clavicle is not uncommon in children age <10 years and is usually treated conservatively. Additionally, the 8 year old has minimal pain and is therefore the most stable. The new nurse should be given the most stable patient.

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.

After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F

2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL A normal blood glucose range for an infant is 40-60 mg/dL within the first 24 hours after delivery. A blood glucose level <40 mg/dL indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline low glucose level is symptomatic and should be assessed first.

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to unlicensed assistive personnel? Select all that apply. 1. Administer artificial tears if the client reports eye dryness 2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request 4. Reinforce to the client that fever is expected with thyrotoxicosis 5. Return a call to the client's family telling them the client's condition is unchanged

2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request UAP are authorized to perform activities of daily living, hygiene, linen changes, and positioning. Therefore, Option 2 and 3 are within a UAP's scope of practice. Option 1 involves medication administration, which is under the scope of a RN. Option 4 involves client teaching and also falls in the scope of practice of a RN. Although placing a phone call can be delegated, providing family with updates about the client's condition may require teaching and psychosocial support; therefore, Option 5 is not an appropriate task for UAP.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete and the client is awake

2. Call the client's medical power of attorney to provide consent for the additional procedure Clients unconscious or under the influence of mind-altering drugs (e.g., opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent. It is in the client's best interest to have the hernia repaired now rather than go through the physical and financial strain of a secondary surgery.

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? 1. Client with a paralytic ileus following a colon resection who has abdominal distention, no audible bowel sounds, and nausea 2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg and pulse of 110/min 3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F 4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg and pulse of 110/min The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities, and esophageal varices that increase the risk for hemorrhage. The nurse should monitor signs of hemodynamic instability and notify the health care provider of any significant changes from baseline as immediate.

Which client should the charge nurse assign to the room closest to the nurses' station? 1. Client with a Salem sump tube to continuous suction who is deaf 2. Client with gastroenteritis and dementia who wanders 3. Client with herpes zoster under airborne isolation precautions 4. Client with sickle cell crisis who requires frequent intravenous opioids

2. Client with gastroenteritis and dementia who wanders The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room closest to the nurses' station as a confused client requires frequent checks and this allows the staff to respond quickly if necessary.

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? 1. Ask if the client can go without the oxygen for 2 hours 2. Delay discharge until the oxygen is delivered 3. Notify the HCP to see what action should be taken 4. Send a hospital oxygen tank home with the client

2. Delay discharge until the oxygen is delivered The nurse needs to assure that the client has the essential equipment/supplies for a smooth discharge into the home environment. The safest option is to delay discharge until that can be accomplished.

The nurse is assisting the health care provider with a lumbar puncture in the client's room. The unit secretary calls over the room intercom and tells the nurse that the laboratory is on the phone with a critical value report for one of the nurse's other clients. What action should the nurse take? 1. Ask the unit secretary to write down a message from the laboratory personnel 2. Instruct the unit secretary to have the charge nurse receive the report 3. Leave the room to talk to the laboratory on the phone and then return immediately 4. Tell the unit secretary to have laboratory personnel send a written result

2. Instruct the unit secretary to have the charge nurse receive the report A critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. The nurse should delegate the task to the charge nurse so appropriate interventions can be initiated while the nurse finishes the sterile procedure. This is the option with the least client risk. Timely reporting of critical results in part of the International Patient Safety Goals.

An emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Five year old with a superficial leg laceration 2. Lethargic 3 month old with diarrhea for the past 12 hours 3. Seven year old with a elevated temperature of 101 F and hematuria 4. Seventeen year old with severe, acute abdominal pain

2. Lethargic 3 month old with diarrhea for the past 12 hours Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic, indicating a change in LOC.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1. Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker

2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately The RN can safely delegate taks to the UAP that promote client safety during toileting and ambulating. Alterations in gait, balance, and range of motion places the client at a higher risk for falling. Evaluating the client for gait and balance deficits requires assessment and is a function of the registered nurse. The UAP may assist the client in ambulating with assistive devices, but evaluating and educating are not delegated.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. 1. Complete and file an occurrence report 2. Right click on the entry and modify it to reflect the correct information 3. Document the correct information and end with the nurse's signature and title 4. Obtain a co-signature form the RN who witnessed the waste of the remaining 1 mg 5. Document in a nurse's note in the client's record detailing the corrected information

2. Right click on the entry and modify it to reflect the correct information 3. Document the correct information and end with the nurse's signature and title 4. Obtain a co-signature form the RN who witnessed the waste of the remaining 1 mg 5. Document in a nurse's note in the client's record detailing the corrected information Electronic health records will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a co-signature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain 2. Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL (16.7 mmol/L) 3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) 4. Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr

3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) This client is experiencing systemic inflammatory response syndrome (SIRS), which can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. These clients require aggressive fluid resuscitation and treatment to address possible causes.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain 2. Client with gastroparesis who reports persistent nausea and vomiting 3. Client with intractable lower back pain who reports new urinary incontinence 4. Client with Meniere disease who reports increasing tinnitus

3. Client with intractable lower back pain who reports new urinary incontinence Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia, and bowel and bladder incontinency (late sign). Cauda equina syndrome is a medical emergency.

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? Select all that apply. 1. "Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation." 2. "Client reports that IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor HCP notified." 3. "Heparin infusion running at 15 untis/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, aPTT 65 sec. HCP notified; will draw labs again at 1:20 PM." 4. "IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour." 5. "Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings."

3. "Heparin infusion running at 15 untis/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, aPTT 65 sec. HCP notified; will draw labs again at 1:20 PM." 4. "IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour." Documentation should be clear, concise, and accurate to be credible, which includes being timely, truthful, and appropriate. When charting a symptom or situation, the nurse should chart the interventions taken and the client response. An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying condition. Adverse event must be acknowledged and documented in the chart. It is essential for the nurse to note the actions taken in response to the event and the time frame in which they were performed. Documenting the key, pertinent negatives indicating that no client harm resulted and the appropriate interventions implemented to rectify or reduce harm will minimize nursing liability. If an incident report is also required, it is separate from the medical record and should never be mentioned in the client's chart.

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? 1. Assess skin to determine severity of burns and wounds 2. Assign client to a cot with other similarly triaged clients 3. Assist the client to the designated showering area 4. Prepare supplies to establish intravenous access

3. Assist the client to the designated showering area In the event of a disaster involving the release of hazardous substances, decontamination is vital to limit injury to the client and prevent exposure to other clients and staff. Disaster triage areas typically include a decontamination area. As long as the chemical remains on the skin, further injury may occur.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security 2. Call the police 3. Call the nursing supervisor 4. Lock the coworker in the medication room until help is obtained

3. Call the nursing supervisor Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1. Call the police 2. Cut up the photograph and throw it away 3. Call the nursing supervisor and report the occurrence 4. Call the laboratory and ask for the name of the individual who sent the photograph

3. Call the nursing supervisor and report the occurrence Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker and is an abusive behavior. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately.

A client with end stage renal disease, oxygen dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the health care provider (HCP) stat 3. Check the apical pulse 4. Check the blood pressure

3. Check the apical pulse The nurse should assess the client first and then call the HCP. A stat page is not needed when the client is DNR.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields. 4. Voided x 1

3. Inspiratory wheezes heard in bilateral lower lung fields. The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. Option 3 best fits these criteria.

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? 1. Student who feels well but is concerned about possible exposure to viral meningitis at an off campus party 2 weeks ago 2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic stricken with severe vaginal pain 4. Student with itchy, cottage cheese like vaginal discharge who is sexually active and worried about having a sexually transmitted infection

3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic stricken with severe vaginal pain Sexual assault is a medical emergency requiring a thorough head to toe physical examination by a specially trained health care provider (eg sexual assault nurse examiner) to identify and treat injuries.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashed to the eyes are classified as emergent and are the highest priority.

The LPN with 20 years of experience approaches the new graduate RN during orientation. The LPN states, "The only difference between you are me is the size of our paychecks." What would be the best response for the new graduate RN to make initially? 1. Assert being the manager of the client team 2. Emphasize the additional education received 3. Explain the legal difference in the scope of practice 4. Focus on the need to work together for quality client care

4. Focus on the need to work together for quality client care Team building involves recognizing that everyone has personal strengths and specific skill sets that together can be used to provide quality client care. The new graduate should recognize the contributions of the LPN and give respect to the LPN rather than initially be confrontational. Emphasizing common goals, such as safe, quality client care, is usually more effective than debating personnel qualifications.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity. 2. Remove jewelry and constricting clothing from the victim. 3. Place the extremity in a position so that it is below the level of the heart. 4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4. Move the victim to a safe area away from the snake and encourage the victim to rest. In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of the client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

A client with AIDS treated for intractable seizure is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? 1. Room 1 - client with Clostridium difficile 2. Room 2 - client with fever of unknown origin 3. Room 3 - client with bacterial pneumonia 4. Room 4 - client with upper gastrointestinal bleed

4. Room 4 - client with upper gastrointestinal bleed The best option is room 4 as the client with the upper gastrointestinal bleed does not put the immunocompromised client with AIDS at increased risk for infection.

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? 1. Firmly indicate that the HCP cannot speak to the nurse in that manner 2. Immediately apologize and attempt to fix the situation 3. Say nothing and let the HCP vent frustrations 4. State that the conversation needs to take place in private and walk to a room

4. State that the conversation needs to take place in private and walk to a room When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference.

The nurse has received the client assignment for the day. Which client should the nurse care for first? 1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the primary health care provider because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy. The client who has a mastectomy is expected to have sensations of tightness and pulling.

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea The nurse should first administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea.

The RN on a medical-surgical unit is working with a LPN and UAP. Which tasks are most appropriate to assign to the LPN? Select all that apply. 1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 2. Assessing fluid volume status of a client with heart failure who is schedule for discharge 3. Assisting with bathing, feeding, and dressing a client with multiple sclerosis 4. Performing wound care and sterile dressing change for a client with a stasis ulcer 5. Providing incontinence care and linen change for a client with diarrhea

1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 4. Performing wound care and sterile dressing change for a client with a stasis ulcer Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan. Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN.

The nurse is triaging client in the emergency department. Which client needs to be seen first? 1. 18 year old female with fever, suprapubic pain, and dysruia 2. 21 year old male with diffuse abdominal pain and a rigid abdomen 3. 64 year old male with a pulsatile mass in the periumbilical area and back pain 4. 75 year old with nausea, fever, and left lower quadrant pain

3. 64 year old male with a pulsatile mass in the periumbilical area and back pain Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1 day post tubal myringotomy client with purulent tympanic drainage 2. A 4 day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae 3. A 10 day old client with a patent ductus arteriosus who has a continuous murmur 4. A 6 year old client with epiglottitis who is drooling and has a severe sore throat

4. A 6 year old client with epiglottitis who is drooling and has a severe sore throat Epiglottitis refers to inflammation of the epiglottis that may result in life threatening airway obstruction. This client should be assessed first due to being unstable from an airway disorder. Option 2 could indicate endocarditis, however this is a circulation disorder and would therefore need to be seen second.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion. The float nurse would not be familiar with the location of diabetic teaching materials, documentation procedure, or referral resources.

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and photophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge 4. Client with sudden onset of the "worse headache of my life"

4. Client with sudden onset of the "worse headache of my life" A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel.

Which tasks can the registered nurse safely delegate to unlicensed assistive personnel? Select all that apply. 1. Ambulate an oxygen-dependent client to the bathroom 2. Assist client with dentures to perform oral suctioning after the client's meal 3. Document pulse oximetry of a client with chronic obstructive pulmonary disease 4. Instruct a client with pneumonia on use of the incentive spirometer 5. Turn and reposition a client with pneumonia

1. Ambulate an oxygen-dependent client to the bathroom 2. Assist client with dentures to perform oral suctioning after the client's meal 3. Document pulse oximetry of a client with chronic obstructive pulmonary disease 5. Turn and reposition a client with pneumonia UAP may assist stable clients with activities of daily living, hygiene needs, ambulation, and turning and repositioning. UAP may also collect and record vital signs (eg pulse oximetry); obtain and set up equipment; and take precautions to prevent aspiration (eg oral care and suctioning)

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply. 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 3. Evaluating partial thromboplastin time in a client receiving heparin 4. Measuring a client with chronic heart failure for compression stockings 5. Teaching a client with a new prescription for warfarin about bleeding precautions

1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 4. Measuring a client with chronic heart failure for compression stockings It is within the scope of practice of the LPN to administer most anticoagulant medications and measure/apply compression devices. Evaluating data and initial education is in the RN's scope of practice.

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift

1. Administering hydromorphone without a prescription 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense and is reportable in all states (Option 4). Abandonment (eg leaving without proper replacement of personnel) is reportable in all states (Option 5).

The charge nurse is reviewing clients' medical records on the cardiovascular care unit. Which client care outcomes are appropriate? Select all that apply. 1. Client receiving a continuous heparin infusion for a DVT remains free of petechiae or purpura 2. Client who had a carotid endarterectomy maintains a heart rate <100/min and blood pressure >90/60 mm Hg with no neurological changes 3. Client who had a percutaneous coronary intervention maintains a chest pain level of <4 on a scale of 0-10 while at rest 4. Client with hypertension receiving IV furosemide remains free from muscle cramping in the extremities 5. Client with peripheral arterial disease following a femoral-popliteal angioplasty remains free of leg pain during ambulation

1. Client receiving a continuous heparin infusion for a DVT remains free of petechiae or purpura 2. Client who had a carotid endarterectomy maintains a heart rate <100/min and blood pressure >90/60 mm Hg with no neurological changes 4. Client with hypertension receiving IV furosemide remains free from muscle cramping in the extremities 5. Client with peripheral arterial disease following a femoral-popliteal angioplasty remains free of leg pain during ambulation Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg petechiae, purpura) (Option 1). Client having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg hypotension, tachycardia) or neurological impairment (eg decreased LOC) (Option 2). Clients receiving IV furosemide, a lop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg muscle weakness, cramps, cardiac arrhythmia) (Option 4). A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia (eg leg pain) (Option 5).

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. "I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset."

2. "I hope others will be helped through my involvement." Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and propose of the study. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. Refuse to float to the ICU based on lack of unit orientation 2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment 3. Ask the nursing supervisor to review the hospital policy on floating 4. Submit a written protest to nursing administration, and then call the hospital lawyer

2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack o knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

The nurse receives the hand off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? 1. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances, and potential cardiac dysrhythmias.

The nurse is reviewing new laboratory values. Which client would be the priority to report to the health care provider? 1. Client 2 days after a hip arthroplasty with a white blood cell count of 12,000/mm3 2. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L 3. Client admitted for end stage renal disease with a creatinine of 3.6 mg/dL 4. Client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL

2. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction, heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. Severely elevated creatine kinase levels, typically >15,000 U/L are observed iwth severe muscle damage and can be a precursor to kidney injury.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? 1. Client 3 days following a myocardial infarction who is on 6 L of oxygen and report nausea 2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO 3. Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min 4. Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client who BP is controlled by oral medication, and has the knowledge and skill to assess vital signs. Unstable angina (angina at rest) is a medical emergency that requires specialist-level monitoring and intervention.

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply. 1. Client in sickle cell crisis receiving oxygen via face mask 2. Client who drank a 1 L bottle of vodka 2 hours ago 3. Client who hears voice commands to kill a coworker 4. Client with mania who has not eaten in 5 days 5. Client with ST elevation on ECG monitoring

2. Client who drank a 1 L bottle of vodka 2 hours ago 3. Client who hears voice commands to kill a coworker 4. Client with mania who has not eaten in 5 days To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol).

A nurse working in the office of a HCP must respond to client telephone messages. The nurse should return which call first? 1. Client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone. 2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot 3. Client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting 4. Client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot Musculoskeletal injuries and immobilization devices (cast) can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia is an early sign of neurovascular impairment. It would be important for the client to report to the HCP for immediate evaluation.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

2. Do the characteristics of the sample population match those of the nurse's unit? When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results.

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes 2. Get directions about care from the client's sister 3. Prepare for emergency intubation 4. Request that the sister provide a living will

2. Get directions about care from the client's sister A medial POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances. The client's sister is designated as her POA. Though spouses are typically POA, option 1 is incorrect as he is not the designated POA. Option 3 would be appropriate only if there were no advance directives or family member present. Option 4 delays treatment.

Nursing staff members are sitting in the lung taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease form her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? 1. Libel 2. Slander 3. Assault 4. Negligence

2. Slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The nurse has just received report on the telemetry unit. Which client should be seen first? 1. The client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases 2. The client 4 hours post permanent pacemaker insertion that is 100% paced 3. The client with a DVT who has a dose of enoxaparin due 4. The client with coronary artery disease and atrial fibrillation who has a dose of warfarin due

2. The client 4 hours post permanent pacemaker insertion that is 100% paced 3. The client with a DVT who has a dose of enoxaparin due The client with a DVT should be seen first. The client has a current clot and is at risk for development of a pulmonary embolism if the clot mobilizes. Enoxaparin is a low molecular weight heparin given as an anticoagulant and should not be delayed.

The nurse notifies the health care provider of a change in client condition. Which of the following report given by the nurse includes the most appropriate and complete information? 1. "A 43 year old client with pneumonia in room 343 has wheezing, crackles, and diminished breath sounds. Temperature is 101.2 F, respirations are 36/min, and pulse oximeter shows 90%. I think the client may need arterial blood gas testing." 2. "A 75 year old client in room 474 is in respiratory distress. The respiratory therapist gave a breathing treatment, but the client is deteriorating rapidly. The RT did not hear left side breath sounds and recommends a chest x-ray." 3. "An 80 year old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen flow rate?" 4. "The client with pneumonia in room 265 is reporting shortness of breath. The RT gave the client a breathing treatment 30 minutes ago, but the client is no better. Would you like to prescribe any laboratory tests or make any changes to the treatment?"

3. "An 80 year old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen flow rate?" The SBAR provides a framework for communicating information about a change in client status to the health care provider. The report given by the nurse in Option 3 contains the most appropriate and complete information. The nurse includes pertinent data related to history, admission, and present treatment; indicates when and what changes occurred; and requests a prescription from the HCP.

Which client does the nurse assess first after receiving the morning report? 1. Client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now 2. Client is 1 day postoperative colectomy; nigh nurse medicated client with morphine 15 minutes ago 3. Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving 4. Client is 3 days postoperative total knee replacement; waiting to be discharged

3. Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication.

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? 1. 22 year old with sickle cell anemia admitted for acute pain crisis 2. 26 year old with pneumonia reporting sharp right side chest pain on deep inspiration 3. 55 year old who is 1 day postoperative vowel resection reporting pain at the incision site 4. 67 year old with obstructive sleep apnea reporting pain at the fractured right tibia

4. 67 year old with obstructive sleep apnea reporting pain at the fractured right tibia Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea and hypopnea, resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. The nurse should assess LOC, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 2- minutes and has a duration of 3-4 hours.

The charge nurse on medical surgical step down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65 year old client 1 day postoperative left femoral popliteal bypass graft surgery with a diminished pedal pulse 2. 66 year old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75 year old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right sided paralysis 4. 78 year old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

4. 78 year old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care, and provide diabetic teaching for this client.

The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider? 1. 36 year old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg 2. 56 year old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60 year old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL, and reports nausea and itching 4. 82 year old client with a pressure injury who has a change in mental status, temperature of 96.4 F, pulse of 110/min, and blood pressure of 96/72 mm Hg

4. 82 year old client with a pressure injury who has a change in mental status, temperature of 96.4 F, pulse of 110/min, and blood pressure of 96/72 mm Hg Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection, that results in potentially life-threatening organ impairment. Because of altered immune function, older adults often do not develop typical signs of infection (eg fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicators of infection (eg altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality.

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3 year old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2. A 7 year old has had a high fever, cough, and sore throat for the past 2 days 3. A 12 year old with asthma controlled with a corticosteroid inhaler developed oral white patches 4. A 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain

4. A 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16 year old needs to be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery.

The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1. A client who has a tympanic temperature of 99.8º F 2. A client who has a regular radial pulse of 96 beats/min 3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85%

4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is needed to maintain the client's oxygenation status. A tympanic temperature of 99.8º F is mildly elevated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96 beats/min is elevated as is the supine resting blood pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than respiratory status.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client schedule for physical therapy for the first crutch walking session 4. A client with a white blood cell count of 14,000mm3 (14x10/L) and a temperature of 38.4 C

4. A client with a white blood cell count of 14,000mm3 (14x10/L) and a temperature of 38.4 C The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are a priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasoogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift Airway is always the highest priority , and the nurse would attend to the client with asthma who request a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients 2. A staff member is assigned to determine the client's needs at home and begin discharge planning 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP) 4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients

4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV rout 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L) 3. Client undergoing ultrafiltration for congestive heart failure 4. Client with a prescription for routine hemodialysis who has chronic renal failure

4. Client with a prescription for routine hemodialysis who has chronic renal failure The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. With Option 1, there is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. The Option 1 client should be assigned to a more experience nurse.

Which client is most appropriate for the 7:00AM-7:00PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin The nurse from a general medical-surgical unit should be familiar with the assessment, nursing care, nursing diagnoses, and medications administered to clients with heart failure and with the facility's protocol for administration of a continual IV heparin infusion.

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply? 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level

4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level Potassium-sparing diuretics, ACE inhibitors and angiotensin II receptor blockers (candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia. Aminoglycosides (tobramycin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity.

Which client should the nurse assess first? 1. Client with atrial fibrillation with a new prescription for warfarin 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% 3. Client with postoperative pain rated 8 out of 10 4. Client with third degree heart block with a pulse of 42/min

4. Client with third degree heart block with a pulse of 42/min Third degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output. This client is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance 2. Exert coercion on the AP 3. Provide a positive reward system for the AP 4. Confront the AP to encourage verbalization of feelings regarding the change

4. Confront the AP to encourage verbalization of feelings regarding the change Confrontation is an important strategy to meet resistance head-on. Face to face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client 2. Ask the AP to find out when the last pain medication was given to the client 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4. Every 30 minutes The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.