*HURST REVIEW Qbank/Customize Quiz - Leadership

What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Inform the client of the need to avoid irritants such as carbonated beverages. 2. Ask client if they are eating small, frequent meals. 3. Monitor for GI upset 30 minutes after meals. 4. Remind the client to avoid tight fitting clothes.

4. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 1. Incorrect: Informing is the same thing as teaching. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 2. Incorrect: The RN is responsible for collecting data. 3. Incorrect: The RN is responsible for assessment and evaluation.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 1. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 2. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. It is not a routine task. 4. Incorrect: The nurse cannot assign teaching to the UAP.

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? Select all that apply 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1., 2., & 5. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. The client is apparently stable and does not require any advanced assessment skills or specialized care. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Did you recognize ureterolithiasis as "kidney stones"? Yes! So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 3. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. 4. Incorrect: What seems to be going on with this client? The abdominal pain is worsening. This could indicate a worsening of this client's condition. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. One important aspect is encouraging the flow of ideas between management and staff members. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. When staff do not feel vested in any new process, there is a sense of underappreciation. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 2. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Assigning blame for the changes to administration will not help staff adjust.

The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. What action should the nurse implement first to ensure client safety? 1. Take report on the most critical clients first. 2. Encourage the staff to help each other. 3. Assign one additional client to each nurse. 4. Call the nursing supervisor to request additional staff immediately.

4. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. The nurse should call for immediate help so that a safe care environment is maintained for all clients. The charge nurse should notify the nursing supervisor who will seek additional staff. The nursing supervisor may be able to assist with client care until another nurse can come in to work. 1. Incorrect: The critical clients are important, but all clients must be considered. The charge nurse must evaluate each client's status and needs to assign the appropriate staff to care for them. The safety of each client must be reviewed. 2. Incorrect: The charge nurse may encourage the staff to work together. This is a positive action but the priority for the charge nurse is to ask for additional staff to maintain safe nursing care. 3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing can be obtained. However, calling the nursing supervisor to request help is the first action.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, postpartum infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical. 2. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This group of clients needs specialized care. 4. Incorrect: No, the monitoring is too specific for the med-surg nurse.

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? Select all that apply 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1., 2., 4., & 5. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. An adult (18 years or older) can create an advanced directive. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 3. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document.

Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Select all that apply 1. Talk to each nurse about concerns related to assigned clients. 2. Call the family of a client suffering from dementia to discuss long term care placement. 3. Briefly assess every client. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client.

1., 4., & 5. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. 2. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 3. Incorrect: The charge nurse does not have to assess every client. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift.

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing? 1. Draining the colostomy bag on a client with diarrhea. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

3. Correct: Traction should never be relieved without a primary healthcare provider's prescription. It can result in muscle spasm and tissue damage. This client could be transferred with traction still maintained. 1. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 2. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Each ROM movement should be repeated 5 times during the session. 4. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. The nurse would then start the 24 hour urine once the 1st void has been discarded. The nurse also needs to be aware of the color and amount of urine voided.

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/LVN to the floor. Which clients would be appropriate assignments for the LPN/LVN? Select all that apply 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catheterization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1, 3 & 5. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 4. Incorrect: Atrial fibrillation places the client at risk for blood clots. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assessing this client and titrating the diltiazem requires the skills of an RN. 6. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN.

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning

1. & 4. Correct: Hot water may damage dentures so intervention is needed. Dentures should be stored in a denture cup. 2. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 3. Incorrect: Moistening the dentures will ease insertion. 5. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped.

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1., 2., 4., & 5. Correct: The client who has a cast and requires pain medication is a stable and predictable client. This client needs ongoing monitoring which is within the scope of practice for the LPN. The client with chronic emphysema has expected shortness of breath. This client is stable and predictable. The client post PEG placement is stable. The LPN can monitor the wound and provide care to the PEG insertion site. The client with cystitis is stable and has a predictable outcome. It is within the LPNs scope of practice to administer antibiotics. 3. Incorrect: This client does not have a predictable outcome. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. This client will also need a lot of education regarding anti-rejection medications.

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogastric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined.

The nurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

2. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. This client is not the nurse's first priority. 3. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 4. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distention in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

3. Correct. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 1. Incorrect. This is not within the scope of practice for the UAP. The nurse must assess and evaluate.Checking the bladder for distention is an assessment that requires the nurse's attention. 2. Incorrect. This client is not stable if having episodes of syncope that could be related to orthostatic hypotension. Since the client is not stable, the UAP should not obtain the client's BP. The nurse should assess the client. 4. Incorrect. The nurse cannot delegate an assessment or evaluation task to the UAP. This is beyond the scope of practice for the UAP.

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

2. Correct: Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served. The key word in the stem is first. The other options may be correct but are not the best first action. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. The reason for the UAP not feeding the client needs to be determined. 3. Incorrect: The nurse retains the responsibility for the delegated task. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. 4. Incorrect: The concern here is the client being fed their meal. Speak to the UAP first and then decide if a between meal supplement is needed.

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.

2. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 1. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 4. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure.

The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which response by the LPN is appropriate in response to the inappropriate delegation? 1. Notify the primary healthcare provider. 2. Refuse the delegated intervention. 3. Discuss the assignment with another LPN. 4. Ask the charge nurse to evaluate the intervention.

2. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. 1. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. This is not a situation that requires the LPN to notify the primary healthcare provider. 3. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. The LPN should refuse the intervention. 4. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Only the state Board of Nursing can legally determine the LPN's scope of practice.

A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse considers various ideas submitted by team members. What proposal would the nurse determine to best meet the needs of families and clients in long term care? 1. Plan all care to be completed in early morning to allow afternoon for visitation. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. 3. Encourage clients and families to develop mutually appropriate visitation times. 4. Allow families unlimited visitation around the clock to meet their schedules.

3. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 1. Incorrect: This is not completely practical for everyone. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. This schedule may leave some clients too exhausted to visit with family. 2. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. A two-hour limit on visits discourages quality time. 4. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catheterization with a decreased pedal pulse below insertion site.

3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the postpartum unit.

3. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client needs careful monitoring and specialized care. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. 1. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. Therefore, this would not be the most appropriate nurse to assign to this client. 4. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assist the float nurse with the clients case. 3. Notify the charge nurse of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a charge nurse or supervisor. This can prevent harm to client's. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The nurse should not lecture, scold or argue with the float nurse. 2. Incorrect: This response overlooks a potentially severe problem. Nurses dependent on drugs or alcohol can harm clients. The nurse should not be assigned to provide care if impairment is suspected. Patient safety must remain the priority. 4. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. The report should contain consequences. Each state BON differs in that also some have treatment programs they administer themselves.

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Correct: Did you notice the hint? Complete blockage of the large intestine. If you give the magnesium citrate, which is a laxative, what will happen? Nothing will get passed the complete blockage. The client would develop severe cramping. This could cause a medical emergency. 1. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. 2. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. This is an appropriate prescription. 3. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO.

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? Select all that apply 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. However, providing care for missing teeth would also be within the LPN scope of practice. 2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen and internal bleeding. This adolescent will require further tests, such as CT scan, and possibly emergency surgery. Because of the complexity of the situation, an RN should be assigned this client. 4. Incorrect: Since these clients were injured during the hurricane, the charge nurse must assume the worst. This client is reporting headache and diplopia; therefore, a safe nurse would consider the possibility of head trauma with brain swelling accounting for the blurred vision. Such potential makes this client serious to critical, and as such, should be assigned to an RN for on-going neurologic assessment. 5. Incorrect: While the trauma of a hurricane could adversely affect the digestive system, the charge nurse would assume the worst and suspect the likelihood the client is having a myocardial infarction. Only an RN can complete the appropriate assessment, testing, and other needs expected with an M.I. client.

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. This individual should be provided appropriate comments of appreciation for this accomplishment. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. It would not be appropriate to overload this new employee with extra work. 3. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. The nurse cannot allow the UAP to perform advanced tasks.

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. An experienced person who can research "best practice" regarding the issue is needed. The best practice committee works to improve clinical practice based on current research. 1. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. The best practice committee utilizes current research in their recommendations. 3. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. The nurse could definitely be part of the committee. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 4. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. The primary healthcare provider may have suggestions but this is not the best first action.

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

1. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This referral would be appropriate. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Aplastic anemia is a rare but serious condition. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated.

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? Select all that apply 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.

1., 2., 3., & 4. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. 5. Incorrect: Medications are not transferred with the client to a new facility. A list of current medications is sent to the facility.

What action should the nurse take after mistakenly administering the wrong medication? Select all that apply 1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. 5. Document medication error and incident (variance) report in nurse's notes.

1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Documentation of what occurred, and the client's assessment is required in the nurse's notes. 5. Incorrect: Do not document that an error was made or that an incident (variance) report was completed. Document what medication was given, the client's assessment, the notification of the nursing supervisor, and primary healthcare provider, and any prescriptions received.

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5. & 6. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. 1. Incorrect: The RN is responsible for teaching. This task cannot be delegated to the LPN/LVN. The LPN/LVN can reinforce teaching. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 3. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. 4. Incorrect: This again is assessment which is the role of the RN only.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Correct: The medical nurse can be assigned to this client. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. The stem does not indicate any loss of neurological function resulting from the seizure activity. 1. Incorrect: This client is exhibiting early signs of increased intracranial pressure. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. An increased temperature will have a direct effect on the brain's metabolism and function. There is a possibility that a hypothermia blanket may be prescribed. 4. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/LVN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/LVN's scope of practice does not include assessment. That task would require an RN or primary healthcare provider. 2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/LVN would not be assigned this task. 4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN. Additionally, the decision to apply oxygen involves assessment of the respiratory system, which also is not within the LPN/LVN's scope of practice.

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Elderly client admitted 30 minutes ago with reports of constipation for four days. Drag and Drop the items from one box to the other

All these clients have a GI problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This is an elderly client who is a new admit. The client reports constipation for 4 days which may be an indication of worse problems. The client is considered unstable until assessed by the nurse. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Did you think dehydration and fluid volume deficit? The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This is normal for clients with hemorrhoids. But the client does need to be assessed prior to the client with Crohn's disease who is improving. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Semi-formed stools are great news! The client is getting better. During exacerbation, the client will have many diarrhea stools.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1., 4., & 5. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. So, the UAP can assist a client to brush and floss teeth. UAPs can assist with elimination and are taught how to measure output. This would be an acceptable task to assign to the UAP. Gathering needed equipment and supplies is within the scope of duties for the UAP. 2. Incorrect: It is out of the UAP's scope of practice to administer medication. This includes medication enemas. Only a plain enema or soap enema can be given by the UAP. 3. Incorrect: The nurse is responsible for evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 6. Incorrect: The nurse is responsible for monitoring a client. This would be out of the UAP's scope of practice. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data.

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? 1. Involve the client in their plan of care. 2. Delegate 2 nurses to work with the client. 3. Accept the client's behavior as confrontational. 4. Encourage the client to be more cooperative.

1. Correct: The client has the right to be involved in the decision making of their care. The healthcare team should recognize the client as the center of the team. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. 2. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. This action is a defensive intervention, and does not address the quarrelsome behavior. 3. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. 4. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns.

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Client reporting epigastric pain and nausea after eating. Female client stating she has been raped. Drag and Drop the items from one box to the other

The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Injuries from a motor-vehicle accident can be life threatening. The client should be assessed first to rule out respiratory difficulty and hemorrhage. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. Elderly clients have special fluid and electrolyte issues after a fall. The cause of the fall may be cardiac, but the question does not indicate this. The third client that should be sent back for treatment is the female client stating she has been raped. We do not know the extent of her injuries based on what the option tells us. There will likely be both physical and emotional injury that needs attention, which places this client third. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. This is likely cholelithiasis, which will need to be checked out. This is the most stable of the four clients which places this client last to be seen.

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago

1. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Therefore, this client would not be a priority over a client who may be experiencing a MI. 2. Incorrect: Dyspnea is one of the three (chronic cough, sputum production, and dyspnea) primary symptoms characteristic of chronic obstructive pulmonary disease. 3. Incorrect: The client is scheduled for the procedure needed for further assessment of angina. This client would be considered more stable than the client who may be having a MI. 4. Incorrect: After a stroke has occurred, medical management is aimed at preventing a second stroke from occurring and rehabilitation. This client may have significant sequelae related to the stroke, but would not be considered acute nor a priority over the client possibly having a MI.

Which task would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

1. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/LVN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/LVN. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Teaching insulin self administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. This should not be delegated to the LPN/LVN.

In which situation should the nurse consult the client's advanced directive? Select all that apply 1. Client scheduled for breast reconstruction after mastectomy. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.

4., & 5. Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. Both of these clients are terminal. 1. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. The option does not say the client is terminal, in a vegetative state, or in a coma. 2. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. 3. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity.

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? Select all that apply 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5 mg PO daily 5. Dexlansoprazole 30 mg PO daily

1., 2., 3., & 4. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. So what is wrong with option #1? Well, do you see the q.d.? This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. Now, in Option #2, we see a dangerous prescription. There is a trailing zero after the prescribed dose. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Administering 3 g/hr IV of morphine would be extremely dangerous. In option #4, we see that the leading zero is missing from the prescription. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. 5. Incorrect: This prescription is written correctly.

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1., 2., 3., & 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 5. Incorrect. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 1. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The charge nurse needs additional information to make a decision. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. 1. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. The charge nurse's best response is to first obtain the needed information to make the best decision. 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. The situation should be explored before bringing the supervisor in on the situation. 4. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Something new could have occurred with the clients, making the assignments too heavy. The charge nurse might not have realized all the responsibilities of taking this team of clients. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients.

The nurse has received the change-of-shift report. What client should the nurse assess first? 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

3. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Compartment syndrome could be developing which can impede circulation and cause nerve damage. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 1. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. 2. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 4. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? No! However, it remains true pain for this client and the client would need intervention to help manage this pain. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome.

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

3. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. This client is at a high risk of infection. We see that the temperature is already elevated, which makes us worry that infection is present. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 1. Incorrect: Although the potassium level of 3.4 mEq/L (3.4 mmol/L) is slightly decreased, this level can be corrected and should improve when the vomiting and diarrhea subside. The nurse should continue to monitor the potassium level, but it does not take priority over the extremely low ANC in the child with fever. 2. Incorrect: This platelet level of 95,000/mm3 is below the normal range of 150,000/mm3 to 400,000/mm3. When the level gets below 100,000/mm3, the clients should be monitored for bleeding such as a nose bleed, which this client has. However, nose bleeds are not that uncommon and can often be controlled by applying pressure to the nares for 5 to 10 minutes. We would not expect to see severe hemorrhage until the levels are much lower, so this client would not be a priority over the client with the low ANC with fever. 4. Incorrect: This hemoglobin level of 9 g/dL (90 g/L) in a child who has reported fatigue is below the normal of 11-15 g/dL (110-150 g/L). However, the fatigue can be managed by regulating the activity to conserve oxygen expenditure and prevent fatigue. The child with the low absolute neutrophil count with signs of an advancing infection would take priority over this child with a slightly low hemoglobin.

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

4. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 1. Incorrect: This client is only 3 months old, which would require specialized skills to evaluate developmental needs. Additionally, nonorganic failure to thrive is a serious situation in which the infant is not getting appropriate nutrition. There could be economic factors, resulting in a lack of food or poor-quality breast milk. Parental beliefs or negligence could also contribute to the situation; therefore, an RN should be assigned to this infant. 2. Incorrect: Although this client is an adolescent, an exacerbation of cystic fibrosis would require careful and frequent respiratory assessments with possible chest physiotherapy. This client would be more appropriate for an RN. 3. Incorrect: A new admission is not appropriate for a nurse sent from the medical surgical unit to the pediatric unit, particularly an LPN, because of the need for initial and frequent assessments. Epiglottitis is a respiratory illness that also impacts the airway. This child should be assigned to an RN.

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? Client eating a simple-carb snack due to weakness. Client reporting a headache and has a fruity breath. Client scheduled for a dressing change to foot ulcer. Client to receive dietary education. Drag and Drop the items from one box to the other

The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Remember, pick the killer answer first! This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). What was the hint? Fruity breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.

The nurse is caring for four clients. Which client should the nurse see first? 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

3. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Remember airway, breathing and circulation (ABCs). Decreased or suppressed respiration are priority. 1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation and if it develops quickly or is severe, coma and seizure may occur. Decreased respiratory rate would be priority. 2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic, and possibly asleep. Make sure the client is safe and in the recovery position. Client would need to be seen soon, but again, decreased respirations takes priority. 4. Incorrect: Decreased or suppressed respirations would be priority over the client needing pre-op medications.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot determine this, the task should not be delegated. This determination is needed to assure client safety is being considered. 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 2. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. If the client is unstable, the nurse would retain the role of measuring the vital signs. Once the client is stable, the UAP could perform this task. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client.