PPL hesi 3
The nurse is planning care for a client who is experiencing acute pain. Which intervention can be implemented by the unlicensed assistive personnel (UAP) in providing personal care for this client? o Guided imagery o Patient-controlled analgesia o Distraction o Biofeedback
o Distraction
The wound care nurse is applying sterile fly larvae to the dead tissue of a client's large wound when a code blue is called for another client on the unit who is not spontaneously breathing. Which action should the nurse take? o Call for assistance. o Close the room door. o Respond to the code. o Finish the procedure.
o Finish the procedure.
The nurse caring for a client with bacterial meningitis is preparing report for the oncoming nurse. It is most important to include which assessment finding in the report? o Increasing pulse pressure o Headache with nuchal rigidity o Photosensitivity o Red macular rash
o Increasing pulse pressure
An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first? o Coordinate a family conference o Define the term heroic measures o Obtain a do not resuscitate prescription o Consult the palliative care team
o Obtain a do not resuscitate prescription
54. The nurse is calling for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goals should the nurse include in the plan of care? (Select all that apply) o Decrease blood pressure o Reduce white blood cell count o Body temperature within normal limits o Negative urine culture o Incision free of exudate
o Reduce white blood cell count o Body temperature within normal limits o Negative urine culture
In planning care for a group of clients, which task should the nurse delegate to the unlicensed assistive personnel (UAP)? o Reinforce teaching provided by the nurse about using the call bell. o Remove the staples from a client's week-old open to air incision. o Demonstrate the proper technique for using a walker to ambulate. o Observe a client's telemetry monitor for changes in heart rhythm.
o Reinforce teaching provided by the nurse about using the call bell.
An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family? o Managed care providers have mandatory pre-certification requirements for hospitalization. o Managed healthcare plans do not pay for any in-hospital medical evaluations. o The client is grieving normally in response to her husband's death and hospitalizations is not necessary. o Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital.
o The client is grieving normally in response to her husband's death and hospitalizations is not necessary.
The charge nurse, along with one nurse, two practical nurses (PN), a unit secretary, and two unlicensed assistive personal (UAP), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the nurse? o The admission assessment of a client diagnosed with bacterial pneumonia o The subclavian dressing change on a client diagnosed with inflammatory bowel disease o Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit o The insertion of a foley catheter for a client diagnosed with septicemia
o The insertion of a foley catheter for a client diagnosed with septicemia
A graduate nurse reports to the charge nurse that a postoperative client's blood pressure is 80/40 mmHg. Which question is most important for the charge nurse to ask? o "What is the client's hemoglobin?" o "What is the client's pulse rate?" o "Is the client feeling dizzy?" o "Has the client recently been medicated for pain?"
o "Is the client feeling dizzy?"
A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment? o A 2-year-old girl with a history of a "cold." Today she is tugging on her ear and has a fever of 102 F (38.9 C). o A 42-year-old male who hurt his back while lifting yesterday. Today he has non-radiating, low- pain rated at 10 on a scale of 1 to 10. o A client at 38-weeks gestation who today noted a small amount of bright red blood on the toilet paper after passing stool. o A 21-year-old with a history of a kidney transplant. Today the client reports "flu-like" symptoms with a fever of 100.4 F (38 C).
o A 21-year-old with a history of a kidney transplant. Today the client reports "flu-like" symptoms with a fever of 100.4 F (38 C).
After receiving the morning shift report, which client should the nurse assess first? o A 64-year-old diagnosed with myocardial infarction who reports being constipated o A 50-year-old diagnosed with an abdominal aortic aneurysm who is reporting severe lower back pain o A 73-year-old diagnosed with chronic obstructive pulmonary disease who has a pulse oximeter reading of 84% o A 45-year-old diagnosed with inflammatory bowel disease who is having diarrhea and weakness
o A 73-year-old diagnosed with chronic obstructive pulmonary disease who has a pulse oximeter reading of 84%
After receiving morning report on an acute care unit, which client should the nurse assess first? o An elderly client whose children are concerned about the care their mother is receiving. o An immobile client who is incontinent and has just soiled the linens. o A client who is shouting loudly because the breakfast trays have not arrived. o A client sitting close to the nurse's station who has been restrained for the past six hours.
o A client sitting close to the nurse's station who has been restrained for the past six hours.
The nurse is assigned to care for four clients. After receiving the change of shift report, which client should the nurse assess first? o A client with diabetes and a history of coronary artery disease who is complaining of increased shortness of breath. o An older client with COPD who is experiencing shortness of breath and whose O2 saturation rate is 88% on room air. o A 29-year-old who has had chronic kidney disease (CKD) for the past year and had an AV fistula placed yesterday. o A 10-year-old with disease who has a morphine PCA pump but is complaining of pain at 2 to 3 on a 10 point scale.
o A client with diabetes and a history of coronary artery disease who is complaining of increased shortness of breath.
The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be retrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager? o Close the door to the room to avoid disturbing other clients in nearby rooms. o Advise the staff nurse to remove the restraints from the client's wrists o Contact the healthcare provider to ensure that a prescription for restraints was written o Determine if the client has a PRN prescription for an antianxiety agent
o Advise the staff nurse to remove the restraints from the client's wrists
It is most important to assign which client to a registered nurse rather than a practical nurse? o Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60, pulse 88, and respirations 14/minute. o One hour after receiving hydromorphone prescribed for q4 hour PRN use, a client reports severe pain o The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced o After ambulating, a postoperative client grimaces and reports incisional at a "9" on a ten-point scale.
o After ambulating, a postoperative client grimaces and reports incisional at a "9" on a ten-point scale.
The nurse who is working on a post-surgical intensive care unit reports regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? o A teenager who had a gunshot would repair yesterday and had quarter-size dark drainage on the dressing o An older adult who had a mastectomy 2 days ago and has 50 mL seroanguinous fluid in the Jackson-pratt (JP) drain o A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills o An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage.
o An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage.
It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client? o A woman who is pregnant with twins and whose due date is one week away. o A 2-year-old who contracted Hepatitis A while at a local daycare center. o A business executive admitted with Guillain-Barre syndrome who has residual POal numbness in the lower extremities. o An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L SI).
o An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L SI).
The charge nurse on a surgical unit is assessing the morning lab work on four clients. Which client's lab finding should be reported to the healthcare provider immediately? o A client scheduled for an elective transurethral resection of the prostate that has an aPTT of 80seconds. o An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL (212 micromol/L) and a BUN of 84 mg/dL (30 mmol/L). o An adolescent who had an emergency appendectomy yesterday and has a WBC of 12,000 mm3 (12*109/L). o A client who had a hip replacement two days ago and has a potassium of 3.8mEq/L (3.8 mmmol/L) and sodium of 147 mEq/L (147 mmol/L).
o An elderly client in end-stage renal disease who has a creatinine level of 2.4mg/dL (212 micromol/L) and a BUN of 84 mg/dL (30 mmol/L).
A nationally known management consultant, whose consulting fee is very high, is scheduled to speak at a day-long hospital education conference. The head nurse wants the information presented at the educational program to be disseminated among the staff. Which plan will be most useful in achieving this goal? o Schedule educational leave for the staff so that all can attend the program o Ask that the program be ordered at three different times so that all shifts can attend o Encourage the education department to schedule the program at a time that is convenient for all staff o Ask two staff members to attend and report what they learned to the unit's staff
o Ask two staff members to attend and report what they learned to the unit's staff
Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement? o Survey the nurses to see who wants to keep the old benefits plan o Determine staff opinion of current healthcare insurance costs o Be available to all shifts to discuss the charges in healthcare benefits. o Announce the new plan at a special employee wellness event
o Be available to all shifts to discuss the charges in healthcare benefits.
Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump? o Magnesium in normal saline prescribed for hypomagnesemia o Ceftriaxone in 5% dextrose in water prescribed for pneumonia o Heparin in normal saline prescribed for deep vein thrombosis o Regular insulin in normal saline prescribed for ketoacidosis
o Ceftriaxone in 5% dextrose in water prescribed for pneumonia
An older woman with a long history of hypertension is transferred from a long-term care facility to the hospital intensive care unit because of an exacerbation of heart failure (HF). She has a signed and witnessed "do not resuscitate" from in her record. Which action should the nurse take? o Ask the unit supervisor to meet with the family about desired care level. o Confirm current resuscitation wishes with client and family. o Consult with hospice case manager regarding plan of care. o Transfer client to a palliative care unit for further supportive care.
o Confirm current resuscitation wishes with client and family.
The nurse calls the surgeon to report that a male client transitioned from a patient controlled analgesic (PCA) pump to a PO analgesic one hour ago is now complaining in a loud voice and asking for the PCA pump. The nurse explains that the client's behavior is disturbing his roommate. The client's blood pressure has increased from 120/72 mmHg to 150/98 mmHg. Which question is best to include in the recommended component of the SBAR report to the surgeon? o Why has the client become so agitated? o Can the PCA pump be initiated and prescribed for an additional 12 hours? o Could the client's behavior be a manifestation of drug seeking behaviors? o Can the client be transferred to a private room?
o Could the client's behavior be a manifestation of drug seeking behaviors?
When making assignments on a psychiatric unit, it is most essential for the charge nurse to assign a nurse to a client with o Depression, who was admitted during the night and denies any suicide ideations. o Bipolar disorder, who requires discharge teaching prior to going home. o Chronic alcoholism, who is being discharged to a half-way house. o Schizophrenia, who has been on the unit for 4 days and is attending scheduled activities.
o Depression, who was admitted during the night and denies any suicide ideations.
The nurse is working at a diabetic clinic with a practical nurse (PN). Which nurse care is best to assign to the PN? o Assess cause of nausea and vomiting for past 2 days. o Describe meaning of Hgb A1C result of 9.9%. o Observe first attempt at self-administration of insulin. o Perform dressing change stage 2 ankle ulcer.
o Describe meaning of Hgb A1C result of 9.9%.
To help prevent litigation by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will o Discuss how to handle complaints from clients and/or their families o Describe how to obtain legal services if needed o Demonstrate how to complete an adverse occurrence or variance report o Maintain personal malpractice insurance
o Discuss how to handle complaints from clients and/or their families
The nursing sta expresses concern about new policy that increases the nurse-to-patient ratio by 25% on all shifts. Which action is best for the nurse-manager to take? o Disseminate factual information to all nursing staff to avoid misinformation and rumors. o Request a judgement from the state board of nursing regarding safety of the new policy o Provide a virtual forum or chat room to discuss the increased nurse-patient ratio o Encourage the nursing staff to organize a group meeting to voice their complaints.
o Disseminate factual information to all nursing staff to avoid misinformation and rumors.
The nurse is caring for a group of clients with help of an experienced unlicensed assistive personnel (UAP). Several specimens need to be collected and sent to the lab. Which specimen collection can the nurse delegate to the UAP? o Drainage from pressure ulcer o Fecal drainage sample o Urine from indwelling catheter o Sample of chest tube drainage o Incisional would drainage
o Fecal drainage sample o Urine from indwelling catheter
A male client is admitted with diffculty breathing related to diagnoses of metastatic lung cancer. He tells the nurse that he does not want to be "hooked up to any machines." His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mmHg, respiratory rate 30 breaths/minute, and oxygen saturation rate is 88%. Which action should the nurse take? o Ask the palliative care team to speak with the client. o Discontinue the intravenous infusion. o Obtain the client's legal records for power of attorney. o Give analgesic medications PRN.
o Give analgesic medications PRN.
An older adult woman with Cushing's syndrome is scheduled for cataract surgery in the day surgery unit. Nursing assessment reveals a rounded face and pitting edema in the lower extremities. Which intervention should the nurse implement? o Notify the surgeon of the findings o Initiate intake and output measurement o Reduce the rate of intravenous fluids o Continue with preparation for surgery
o Initiate intake and output measurement
Contact precautions are being implemented for a client with cellulitis of the right foot. The nurse observes an unlicensed assistive personnel (UAP) applying lipstick in this client's room. Which action should the nurse take? o Report the possibility of cross-contamination of infection control. o Send a saliva specimen from the UAP to the laboratory for culture. o Add a staff grooming protocol to the monthly staff meeting agenda. o Instruct the UAP to refrain from placing anything in her mouth.
o Instruct the UAP to refrain from placing anything in her mouth.
A client with leukemia is hospitalized for weakness, fatigue, and anemia. The client is restless and tachycardic. Which intervention is most important for the nurse to include in the plan of care? o Encourage diet supplements with meals o Protect from noise, light, and temperatures. o Monitor for sign of shock o Maintain protective isolation
o Maintain protective isolation
A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care? o Keep head of bed raised 45 degrees o Maintain strict intake and output o Monitor blood glucose level
o Maintain strict intake and output
The nurse hears a newly employed unlicensed assistive personnel (UAP) who is working in a long-term care facility calling the adult residents "honey" and "dearie." What is the best action for the nurse to take? o Role model the correct approach for addressing the residents. o Ask the long term care facility supervisor to rebuke the UAP. o Meet with the UAP to discuss respectful client care strategies. o Call a staff meeting to encourage more professional behaviors.
o Meet with the UAP to discuss respectful client care strategies.
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? o Monitor for signs of bleeding o Complete an adverse occurrence report. o Obtain blood for coagulation studies o Notify the healthcare provider
o Monitor for signs of bleeding
When assessing a client who is returned to the unit following a left nephrectomy, the nurse notes a small amount of bloody drainage at the drain site. Which intervention is most important for the nurse to include in this client's plan of care? o Document temperature every four hours o Turn, cough, deep breath o Provide sips of water and ice chips o Monitor urinary output hourly
o Monitor urinary output hourly
The nursing supervisor sends an unlicensed assistive personnel (UAP) to a medical unit to replace an absent UAP. When delegating the task of obtaining client's blood sugar levels using a glucometer, which action is most important for the nurse to implement? o Ask the UAP to document the results in the electronic client record o Provide the UAP with instructions about how to calibrate the glucometer o Ask the UAP to describe the normal blood glucose levels for fingerstick analysis o Observe the UAP obtain a fingerstick glucose level using the glucometer
o Observe the UAP obtain a fingerstick glucose level using the glucometer
A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which tasks should the nurse to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) o Offer high caloric foods such as milk and ice cream o Maintain a clean and pleasant environment during meals. o Consult with registered dietitian about recommended nutritional needs. o Assist the client with eating small frequent high calorie meals. o Set up the food and drink containers within easy reach.
o Offer high caloric foods such as milk and ice cream o Maintain a clean and pleasant environment during meals. o Assist the client with eating small frequent high calorie meals. o Set up the food and drink containers within easy reac
During a 24-hour chart review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which is the best immediate action for the nurse to take? o Order the lab work as prescribed and follow procedures for completing an incident report o Call the healthcare provider and ask is the prescription is still needed since 12hours elapsed since it was written o Notify the nursing supervisor of the previous shift's omission in not transcribing the prescription o Telephone the nurse responsible for the error at home to report the omission of the transcription
o Order the lab work as prescribed and follow procedures for completing an incident report
A client is transferred to the surgical unit following a strangulated inguinal hernia repair. The post anesthesia care unit nurse reports the total intake and output that occurred during surgery, the sedation reversal agent, and two episodes of emesis post extubation. Which additional information should the nurse provide to complete this report? o Soft abdomen, absent bowel sounds, no bleeding on dressing o Peripheral pulses present with full range of motion of both legs o History of vomiting at home for 3 days prior to surgery o Refuses to take ice chips for complaints of dry mouth
o Peripheral pulses present with full range of motion of both legs
A healthcare provider notifies the nurse that new prescriptions have been written for a client. Which is the first action the nurse should implement? o Collect any needed forms such as laboratory and radiology requisitions. o Clarify the prescriptions with the unit clerk to ensure accurate transcription. o Read all of the new prescriptions for the client written by the provider. o Document the time that the provider visited the client in the nurse's notes.
o Read all of the new prescriptions for the client written by the provider.
The nurse assigns an unlicensed assistive personnel (UAP) to apply sequential compression devices to a client. Which instruction should the nurse include when assigning this task to the UAP? o Report any change in color in the client's feet or legs o Check the client's pedal pulses before applying o Elevate the client's leg on a pillow if the client reports discomfort o The compression should start at the client's toes and move upward.
o Report any change in color in the client's feet or legs
The nurse assigns collection of a sputum specimen to an unlicensed assistive personnel (UAP). Before delegating this task to the UAP, which action is most important for the nurse to implement? o Verify the UAP has read the procedure for collection of sputum specimen. o Determine if the UAP received training to collect sputum specimen. o Assess the client's willingness to allow the UAP to collect the specimen. o Review the institutional policy for delegation with the nursing supervisor.
o Review the institutional policy for delegation with the nursing supervisor.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement? o Review the medication transcription with the nurse. o Evaluate the client for symptoms of a drug interaction o Inform the pharmacist who dispensed the medication o Report the medication error to the nursing supervisor
o Review the medication transcription with the nurse.
After having coronary artery bypass surgery, a client develops a deep venous thrombosis in the left leg. Which nurse should be responsible for coordinating the progression of the client's care? o Risk management nurse o Nurse case manager o Cardiology unit supervisor o Adult nurse practitioner
o Risk management nurse
Because of budget cutbacks, a policy was established which mandates that when the census is low, nurses will be sent home. For the third time in two weeks, a nurse who has been employed at the hospital for three months is sent home immediately after arriving for work. The nurse is obviously upset and begins to cry when told to go home. Which action should the charge nurse take? o Write a letter to administration describing the unfair situation and encourage all employees to sign it o Reassure the nurse that this is hospital policy and has nothing to do with the nurse's capabilities o Call the supervisor and report that the staffing policy has unfairly caused this new employee financial stress. o Take the nurse to a private place and listen to the nurse's description of concerns
o Take the nurse to a private place and listen to the nurse's description of concerns
The charge nurse assigns an experienced practical nurse (PN) to care for a client who needs a complex dressing change. The female PN, who seems anxious with difficult assignments, tells the charge nurse that she does not feel competent to perform the procedure. Which is the best way for the charge nurse to handle this situation? o Tell the PN that assistance is available is needed, but that she will be responsible for the client's care. o Remind the PN that performing sterile dressing changes is within the scope of practice for the practical nurses. o Avoid conflict with the PN and reassign the client to an RN. o Reassure the PN that she is competent to perform the dressing change.
o Tell the PN that assistance is available is needed, but that she will be responsible for the client's care.
The nurse watches an unlicensed assistive personnel (UAP) bring soap, washcloths, and a basin into the room of a male client who had a suprapubic catheter inserted earlier that day. Which action should the nurse implement? o Encourage the UAP to offer the client the opportunity to perform his own catheter care independently o Remind the UAP to provide warmth and privacy when washing and drying the area around the client's catheter. o Tell the UAP that the nurse will perform the client's catheter care after the UAP assists with his personal care. o Advise the UAP that the client's dressing will need to be removed before cleaning around his catheter.
o Tell the UAP that the nurse will perform the client's catheter care after the UAP assists with his personal care.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the-counter laxative for a client who is constipated. What instruction should the nurse provide the unit clerk? o Tell the healthcare provider the nurse will return the phone call as soon as possible. o Be sure to write down what is prescribed and then repeat it back to the healthcare provider. o Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. o Remain with this client and monitor the vital signs while the nurse takes the call.
o Tell the healthcare provider the nurse will return the phone call as soon as possible
The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first? o Tell the staff to keep all clients and visitors in the client rooms with the doors closed. o Instruct the client's family member to stay in the visitor waiting area until further notice. o Call the hospital operator to determine if this is indeed a real emergency or a fire drill. o Direct the nursing staff to evacuate the clients using the stairs in a clam and orderly manner.
o Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
A nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for an acuity ill client required immediate bedside insertion of a chest tube.Which assignment is the best use of each person's skills? o The PN instructs the family about the need for chest tube insertion while the RN obtains vital signs. o The RN inserts the chest tube immediately after the PN cleanses the skin at the insertion site. o The UAP listens to breath sounds while the RN witnesses the informed consent. o The UAP obtains an oxygen saturation level while the RN reports findings to the healthcare provider.
o The UAP obtains an oxygen saturation level while the RN reports findings to the healthcare provider.
The nurse calls a surgeon about a male client who is having abdominal pain after a bowel resection. He received hydromorphone 2 hours ago and is now requesting additional pain medication. Vital signs include temperature 97.8 F (36.6 C), heart rate 112 beats/minute, respirations 24 breaths/minute, and blood pressure is 98/62 mmHg, which is lower from previous reading one hour ago. The client has a history of chronic atrial fibrillation and takes clopidogrel, which was continued until one day prior to surgery. The nurse recommends that the surgeon see the client immediately to evaluate the situation. What information makes this report complete? o Nasogastric suction is draining bile-colored secretions o Lungs are clear bilaterally and oxygen saturation is 97% o The abdomen is rigid, tender to touch, and distended o Client's history includes cardioversion and ablation therapy
o The abdomen is rigid, tender to touch, and distended
The charge nurse needs to determine is an additional nurse should be called to help staff unit for the next shift. Which information is most important for the charge nurse to consider when making this decision? o The skill level of the personnel staffing the unit. o The number of clients leaving the unit for diagnostic tests. o The acuity level of the clients on the unit. o The physician's plans to perform procedures on the unit.
o The acuity level of the clients on the unit.
An unlicensed assistive personnel (UAP) is stuck in the palm of the hand by a needle that is found un the bed linen of a client diagnosed with Hepatitis B. Which action should the charge nurse instruct the UAP to do first? o Wash hands with soap and water o Report to the employee health nurse o Have blood test drawn per policy o Complete and file an incident report
o Wash hands with soap and water
A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client o Post-triple coronary bypass four days ago who has serosanguinous drainage in one chest tube. o With an ileal conduit created two days ago with a scant amount of blood in the drainage pouch. o Admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L). o With a pneumothorax secondary to a gunshot with a current pulse oximeter reading of 90%.
o With a pneumothorax secondary to a gunshot with a current pulse oximeter reading of 90%.
