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A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse? A. BUN 15 mg/dL B. Platelet count 60,000/mm3 C. WBC 6,000/mm3 D. Hemoglobin 14 g/dL

B. Platelet count 60,000/mm3

An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? A. "There is a higher risk of infection for our clients associated with artificial nails." B. "You should know that artificial nails have a very unprofessional appearance." C. "I want you to review the facility's policy on personal attire before you begin the shift." D. "Why would you wear artificial nails to work when you know it's against the rules?"

A. "There is a higher risk of infection for our clients associated with artificial nails."

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? A. "This infection is treated with one dose of azithromycin." B. "If your sexual partner has no symptoms, no medication is needed." C. "You have to avoid sexual relations for 3 days." D. "You need to return in 6 months for retesting."

A. "This infection is treated with one dose of azithromycin."

A nurse on a medical-surgical unit has accepted a transfer to the intensive care unit (ICU). Prior to transfer to the ICU, the nurse completes an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence

D. Nonmaleficence

A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP? A. A client who has a lumbosacral spinal tumor B. A client who has Guillain-Barre syndrome C. A client who has amyotrophic lateral sclerosis (ALS) D. A client who has systemic sclerosis

A. A client who has a lumbosacral spinal tumor

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A. A client who has a punctured femoral artery B. A client who has multiple fractures C. A client who has a red rash over his abdomen D. A client who reports severe flank pain radiating to the groin

A. A client who has a punctured femoral artery

A nurse is planning to use an SBAR communication tool when calling a provider. Which of the following statements by the nurse is appropriate for the "B" step in this tool? A. "Client should be seen by a neurologist." B. "Client was found unconscious on the floor in her home." C. "No provider's prescriptions are available." D. "Client disoriented; pupils slow to respond to light."

B. "Client was found unconscious on the floor in her home."

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent policy change regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate? A. "Let's talk about your concerns about the new policy." B. "Why didn't you voice your concerns before the new policy was implemented?" C. "Being open to change is an expectation of the nurses who work on this unit." D. "You should support this policy change because it was based on evidence-based practice."

A. "Let's talk about your concerns about the new policy."

A nurse manager is reviewing information about critical pathways with the unit nurses. Which of the following information should the nurse manager include? A. "Critical pathways should include evidence-based interventions." B. "Critical pathways replace nursing care plans." C. "Critical pathways are used for clients who have rare medical diagnoses." D. "Critical pathways reduce the amount of paperwork involved in client care."

A. "Critical pathways should include evidence-based interventions."

A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching? A. "Disaster drills should be held on a regular basis." B. "An actual disaster cannot take the place of a disaster drill." C. "A staff nurse can function as the incident commander." D. "A physician must triage victims of a disaster in the emergency department."

A. "Disaster drills should be held on a regular basis."

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching? A. "Do not adjust the oxygen flow rate." B. "Check your oxygen equipment once each week." C. "Store unused oxygen tanks horizontally." D. "Use wool blankets on your bed."

A. "Do not adjust the oxygen flow rate."

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A. "Documentation is a communication tool for the interprofessional health care team." B. "Documentation provides informaition to the client about financial charges for care provided." C. "Documentation provides information for a client audit." D. "Documentation allows providers to monitor the nurse's activities."

A. "Documentation is a communication tool for the interprofessional healthcare team."

A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness? A. "I feel as though I met the standard of care. Would you tell me more about your concerns?" B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I am at a loss for words. I always do my best to give good care to my clients." D. "What do you have against me? It must be something or you wouldn't be criticizing my care."

A. "I feel as though I met the standard of care. Would you tell me more about your concerns?"

A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? A. "I have my assignment and will start with room 1, then work my way to room 10." B. "I will give this client his meal tray first, as he is going early to physical therapy." C. "After breakfast, I will pack the belongings of clients who will be discharged this morning." D. "I will start by providing partial baths before breakfast."

A. "I have my assignment and will start with room 1, then work my way to room 10."

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? A. "I need to talk to you about unit expectations regarding delegating and completing tasks." B. "Several staff members have commented that you don't do your fair share of the work." C. "If you don't do your share of the work, I will have to inform the nurse manager." D. "You have been very inconsiderate of others by not completing your share of the work."

A. "I need to talk to you about unit expectations regarding delegating and completing tasks."

A nurse is providing information on pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? A. "I will call for pain medication before the previous dose wears off." B. "I will call for pain medication as my pain starts to increase again." C. "I will wait for you to evaluate my pain before asking for more." D. "I will ask for less medication to avoid addiction."

A. "I will call for pain medication before the previous dose wears off."

A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? A. "If you render aid in an accident, do not leave the scene until another competent person can take over." B. "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse." C. "Federal laws require a licensed nurse to render aid in an emergency." D. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws."

A. "If you render aid in an accident, do not leave the scene until another competent person can take over."

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? A. A client who is postoperative following a lobectomy and has a chest tube B. A client who is being discharged to a long-term care facility C. A client who needs teaching about insulin self-administration D. A client who needs teaching prior to initiating cardiac rehabilitation activities

A. A client who is postoperative following a lobectomy and has a chest tube

A nurse on a pediatric unit is caring for four clients. The nurse should recommend an interdisciplinary client care conference for which of the following clients? A. A client who was diagnosed with cystic fibrosis and has a distended abdomen. B. A client who is 10 hr postoperative from an appendectomy. C. A client who is 6 hr postoperative from a tonsillectomy. D. A client who was diagnosed with acute diarrhea from the Norovirus.

A. A client who was diagnosed with cystic fibrosis and has a distended abdomen.

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances? A. A dependent adult admitted for the treatment of a spiral fracture B. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse C. A young adult client admitted for acute glomerulonephritis following a viral infection D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment.

A. A dependent adult admitted for the treatment of a spiral fracture

A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence? A. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. B. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. C. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.

A. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? A. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy B. An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax C. A middle adult who is 36 hr postoperative from an open laminectomy D. An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32

A. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy

A nurse is planning to assign care activities to the assistive personnel (AP). Which of the following activities are appropriate for assignment to the AP? (Select all that apply.) A. Accompanying a client with depression to occupational therapy B. Assessing a client with hypomania for exhaustion C. Checking the position of a client in soft wrist restraints D. Setting limits with a client who has mania E. Sitting with a client who abuses alcohol whose last drink was two days ago

A. Accompanying a client with depression to occupational therapy C. Checking the position of a client in soft wrist restraints E. Sitting with a client who abuses alcohol whose last drink was two days ago

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions? A. Advocate B. Caregiver C. Manager D. Educator

A. Advocate

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.) A. Ambulate an older adult client who has hypertension. B. Provide discharge instructions for a client who has a new skin graft. C. Perform an admission assessment on a client. D. Check a blood product with another nurse prior to administration. E. Weigh a client who has heart failure.

A. Ambulate an older adult client who has hypertension. E. Weigh a client who has heart failure.

A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take? A. Arrange to complete the assessment with only the client and a translator present. B. Ask the client's partner to translate questions and answers for the client. C. Ask a male student nurse to translate for the client. D. Use an internet website ending in.com to translate for the client.

A. Arrange to complete the assessment with only the client and a translator present.

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? A. Ask what she will be assigned to do. B. Determine if she has the skills to complete the assignment. C. Identify her options. D. Notify the nurse manager about her concerns for client safety.

A. Ask what she will be assigned to do.

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority? A. Attain a weight that is greater than the 75th percentile for age and height. B. Make positive statements about improvements in body image. C. Feel in control of her behavior. D. Identify changes within the family unit that promote the client's autonomy.

A. Attain a weight that is greater than the 75th percentile for age and height.

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A. Call the emergency response team. B. Seek immediate help from the risk manager. C. Call the provider for a stat DNR order. D. Respect the family's wishes and do nothing.

A. Call the emergency response team.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform the charge nurse that the client refused the enema.

A. Check the client's medical record for the provider's prescription.

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not wear tight clothing over the insertion area. D. Request to be scanned with a handheld metal detector when in the airport. E. Do not have a microwave oven in the home.

A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area.

A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? A. Encourage the client to verbalize questions. B. Insist the client take prescribed medications. C. Inform the client that the medication is the same as taken at home. D. Tell the client that refusal of the medication is considered noncompliance.

A. Encourage the client to verbalize questions.

A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? A. Euphoria B. Rhinorrhea C. Hallucinations D. Dilated pupils

A. Euphoria

A severe storm resulted in an RN working with one assistive personnel (AP) on a medical-surgical unit. After talking with the hospital incident commander, which of the following actions by the nurse is appropriate? A. Focus on providing care that prevents life-threatening emergencies B. Reinforce discharge teaching to clients C. Instruct the AP to focus on clients' ADLs D. Stock additional unit supplies

A. Focus on providing care that prevents life-threatening emergencies

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take? A. Focus on providing care that prevents life-threatening emergencies. B. Reinforce discharge teaching to clients. C. Instruct the assistive personnel (AP) to focus on clients' ADLs. D. Stock additional unit supplies.

A. Focus on providing care that prevents life-threatening emergencies.

An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? A. Gather data about the nurse's work performance and attendance history. B. Approach the involved nurse to discuss the behavior. C. Notify the risk manager. D. Refer the nurse to the board of nursing diversion program.

A. Gather data about the nurse's work performance and attendance history.

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care? A. Give positive feedback directly to the AP. B. Tell other nurses what an effective team member the AP is. C. Nominate the AP for the Employee of the Month award. D. Detail the AP's contributions to the nurse manager.

A. Give positive feedback directly to the AP.

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client's family is reached C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine

A. Invoking implied consent

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? A. Keeping an appointment with a client B. Allowing a new mother to hold her stillborn infant C. Confirming that a client going for surgery has signed a consent form D. Refusing to disclose information about a client to the media

A. Keeping an appointment with a client

A charge nurse is observing the actions of an assistive personnel (AP). Which of the following actions by the AP is appropriate? A. Logging off the computer after entering a client's intake and output totals B. Providing her password to a new nurse in orientation so that the new nurse can enter her client's vital signs C. Posting the client's medical diagnosis on a message board in the client's room D. Discarding her nursing activity work sheet in a waste basket at the nurse's station at the end of the shift

A. Logging off the computer after entering a client's intake and output totals

A nurse is working with an interdisciplinary disaster committee to develop a community wide emergency response plan in the event of a non biological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911? A. Office of Emergency Management (OEM) B. Federal Emergency Management Agency (FEMA) C. American Red Cross (ARC) D. U.S. Department of Homeland Security (DHS)

A. Office of Emergency Management (OEM)

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take? A. Pull the curtain around the client's bed. B. Wash the client's arms and hands first. C. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus. D. Fill the bath basin with tap water that is 39° C (102.2° F).

A. Pull the curtain around the client's bed.

A nurse is orienting a group of new graduate nurses and explains the purpose of delegation. Which of the following is an appropriate statement by the nurse? A. "Delegation provides appropriate resources for the client." B. "Delegation permits a designated individual to meet a goal on your behalf." C. "Delegation promotes discharge teaching activities for clients." D. "Delegation decreases health care costs."

B. "Delegation permits a designated individual to meet a goal on your behalf."

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.) A. Repeat the order back to the provider. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record. D. Obtain the provider's signature within 8 hr. E. Implement a recorded order message if the nurse can hear and understand it clearly.

A. Repeat the order back to the provider. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record.

A nurse is caring for a client who has dementia and receives delivery of a daily newspaper. The nurse observes a staff member reading the paper before it is given to the client. Which of the following actions by the nurse is appropriate? A. Report the incident to the unit manager. B. Purchase a new paper for the client. C. Take no action at this time. D. Ask the family for permission to share with the staff.

A. Report the incident to the unit manager.

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints? A. Self-destructive behavior despite alternative interventions B. Coercion to take prescribed medications C. Discipline for throwing objects at staff D. Punishment for verbally abusing other clients

A. Self-destructive behavior despite alternative interventions

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement? A. Sit in front of the group for the meeting and then stand for the announcement. B. Cross her arms over her chest when beginning the announcement. C. Stare at the people the announcement will affect the most. D. Lean gently over the back of a chair sitting to one side of the room when making the announcement.

A. Sit in front of the group for the meeting and then stand for the announcement.

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? A. Take an arterial blood gas (ABG) specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. C. Pass fresh water to clients on the unit. D. Obtain a routine urine sample from a newly-admitted client.

A. Take an arterial blood gas (ABG) specimen to the laboratory.

A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first? A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. B. Report the behavior to the nurse manager. C. Create a written document of the incident and store the document in a safe place. D. Seek help from a trustworthy friend.

A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) A. The date of the incident B. The name of the provider who prescribed the medication C. The potential adverse effects of the medication D. The time the client was to receive the medication E. The client's vital signs

A. The date of the incident D. The time the client was to receive the medication E. The client's vital signs

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? A. The nurse separates the client's labia with her dominant hand. B. The nurse coats the indwelling urinary catheter with lubricant. C. The nurse provides perineal care prior to inserting the urinary catheter. D. The nurse applies the sterile drape prior to inserting the urinary catheter.

A. The nurse separates the client's labia with her dominant hand.

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.) A. The shoulders droop. B. The facial muscles relax. C. The respiratory rate increases. D. The pulse is within the expected range. E. The client draws his legs up into a fetal position.

A. The shoulders droop. B. The facial muscles relax. D. The pulse is within the expected range.

An RN is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following is important for the nurse to understand when delegating tasks to the LPN? A. The state Nurse Practice Act B. The National Association for Practical Nurse Education and Services Standards C. The National Council of State Boards of Nursing Decision Tree D. The Omnibus Budget Reconciliation Act of 1987

A. The state Nurse Practice Act

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? A. Transporting a school-age client who is in traction to another department B. Playing a computer video game with an adolescent who has sickle cell disease C. Reading a book to a preschool client who has AIDS D. Rocking an infant who was admitted for croup

A. Transporting a school-age client who is in traction to another department

A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication? A. "I had strep throat about one year ago." B. "I plan to continue nursing my baby until he is at least a year old." C. "I got my flu shot at the pharmacy two weeks ago." D. "I am allergic to shellfish."

B. "I plan to continue nursing my baby until he is at least a year old."

A nurse manager is reviewing safe delegation practices with nurses on the unit. Which of the following is an appropriate statement by the nurse manager? A. "All delegated task should be performed using outstanding skill." B. "All delegated tasks require follow-up to ensure compliance." C. "All delegated tasks should be observed directly during task performance." D. "All delegated tasks are stopped during poor task performance."

B. "All delegated tasks require follow-up to ensure compliance."

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? A. "I will have to be admitted to a long-term care facility in order to receive hospice care." B. "I should expect the hospice team to help me manage my dyspnea." C. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." D. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."

B. "I should expect the hospice team to help me manage my dyspnea."

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide? A. "You know it's not appropriate for you to ask me that." B. "It's my responsibility to remind you that we have to respect our clients' privacy." C. "It's a minor injury. I'm sure you'll see her back in the neighborhood soon." D. "Oh, what lovely flowers. She will enjoy these."

B. "It's my responsibility to remind you that we have to respect our clients' privacy."

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include? A. "The client attempted to climb over the side rails and fell." B. "The client was lying on the floor next to his bed." C. "The client was restless and trying to get out of bed all evening." D. "The presence of a bed alarm could have prevented the client from falling."

B. "The client was lying on the floor next to his bed."

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)? A. "The client's family members have been present most of the day." B. "The client's blood pressure and pulse have been fluctuating throughout the day." C. "The client discussed having prior thoughts of suicide." D. "The client works in the hospital radiology department."

B. "The client's blood pressure and pulse have been fluctuating throughout the day."

A nurse has listened to a report at the start of the shift. Which of the following statements by the RN during this report indicates that the nurse should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)? A. "The client's family members have been present most of the day." B. "The client's blood pressure and pulse have been unstable." C. "The client discussed having prior thoughts of suicide." D. "The client works in the hospital radiology department."

B. "The client's blood pressure and pulse have been unstable."

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? A. "I will take my pulse weekly." B. "The pacemaker can be checked from home by using the telephone." C. "My pacemaker will need reprogramming if I stand too close to a microwave oven." D. "The next pacemaker check will be when the batteries need to be replaced."

B. "The pacemaker can be checked from home by using the telephone."

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." B. "What do you think your spouse would have wanted?" C. "Most religions support organ donation, so don't let that stand in the way." D. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

B. "What do you think your spouse would have wanted?"

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first? A. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided C. A client who has COPD and the capillary refill time on both hands is 4 seconds D. A client who has late-stage cirrhosis and whose breath has a fruity odor

B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided

A nurse has received morning report on the following four clients. Which client should the nurse see first? A. A client who has a calcium level of 10 mg/dL and reports having a headache B. A client who has a blood glucose of 68 mg/dL and reports mild sweating C. A client who has acute glomerulonephritis and reports reddish-brown urinary output D. A client who has cellulitis of the left lower extremity and reports pain in the affected leg

B. A client who has a blood glucose of 68 mg/dL and reports mild sweating

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A. A client who has diarrhea and requests clear liquids for breakfast B. A client who has a cast on the left leg and reports numbness and paresthesia C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)

B. A client who has a cast on the left leg and reports numbness and paresthesia

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eyesight B. A client who has terminal cancer and needs assistance with pain management. C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work. D. A client who has dementia and needs help with activities of daily living.

B. A client who has terminal cancer and needs assistance with pain management

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all that apply.) A. Self-confessor B. Coordinator C. Evaluator D. Energizer E. Dominator

B. Coordinator C. Evaluator D. Energize

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first? A. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL C. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output D. A client who was administered acyclovir for cellulitis reports pain in the affected leg

B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL

A nurse manager received a client request not to have a particular nurse care for her while at the acute care facility. Which of the following is the most appropriate action by the nurse? A. Document the issue on an incident report. B. Address the concern with the charge nurse. C. Explain to the client the nurse was having a bad day. D. Notify the human resources department.

B. Address the concern with the charge nurse.

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager? A. Ask other staff nurses about the level of care the specific staff nurse provides. B. Address the concern with the specific staff nurse. C. Recommend the specific staff nurse be transferred to another unit. D. Notify the human resources department about the request.

B. Address the concern with the specific staff nurse.

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment? A. Ask each nurse to read the procedure and sign a form acknowledging competency. B. Allow time during the workday when each nurse can demonstrate proficiency. C. Require each nurse to take a written examination about the new equipment. D. Verbally question the staff about the new equipment.

B. Allow time during the workday when each nurse can demonstrate proficiency.

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.) A. Demonstrate the technique to instill eye drops. B. Ambulate a client who has a cane. C. Irrigate a wound. D. Transfer a client to a stretcher. E. Record urinary output.

B. Ambulate a client who has a cane.

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A. A school-age child who has diabetes mellitus and requires blood glucose monitoring B. An infant who has pertussis and is receiving oxygen via nasal cannula C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions D. A toddler who has both arms in casts and needs to be fed his breakfast

B. An infant who has pertussis and is receiving oxygen via nasal cannula

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? A. An expert nurse provides testimony that the nurse should have handled the situation differently. B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. C. The client's attorney states that injury to the client could have been prevented. D. The client's provider testifies the nurse was at fault for the injury.

B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? A. Taking a telephone prescription about a client who is to be transferred from PACU B. Assessing a client who experiences unilateral calf pain when ambulating C. Reinforcing a client's dressing for the surgical site of an above-the-knee amputation D. Reassuring the partner of a client who sustained a closed head injury

B. Assessing a client who experiences unilateral calf pain when ambulating

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Justice

B. Autonomy

A community health nurse is reviewing information about infectious diseases with the nurses on her team. The nurse should remind the team that which of the following diseases are included in the list of nationally notifiable infectious diseases? (Select all that apply.) A. Trichomonas vaginalis B. Chlamydia C. Gonorrhea D. Chancroid E. Candidiasis albicans

B. Chlamydia C. Gonorrhea D. Chancroid

The nurse in a clinic is planning a community diabetes management program and developing goals for this program. Which of the following is an appropriate goal? A. Providers in the area will determine if clients are interested. B. Clients will have a decreased incidence of foot amputations. C. A facility will be reserved for the program. D. Handouts and teaching materials will be distributed at the program.

B. Clients will have a decreased incidence of foot amputations.

A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes? A. Establish a benchmark to identify a standard of performance. B. Compare the number of medication errors before and after the action was implemented. C. Provide the staff with a questionnaire to quantify staff satisfaction with the changes. D. Conduct a study about the time and money costs of implementing the change.

B. Compare the number of medication errors before and after the action was implemented.

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following? A. Determines the client does not have a mental illness B. Confirms the client appears competent to provide consent C. Asserts the nurse has explained the risks and benefits of the procedure D. Records that the client's spouse agrees the procedure is necessary

B. Confirms the client appears competent to provide consent

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly? A. Provide a written procedure for the use of the device for the staff to review. B. Demonstrate using the device and observe the staff returning the demonstration. C. Remind the staff to review the procedure manual prior to using the new pump. D. Identify the differences and new features of the device in a written brochure.

B. Demonstrate using the device and observe the staff returning the demonstration.

A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take? A. Verify the AP's educational preparation prior to delegating the task. B. Determine the time frame the AP should report the results. C. Observe the AP as she obtains the vital signs of each client. D. Ask the AP to take the vital signs of the client returning from surgery first.

B. Determine the time frame the AP should report the results.

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process? A. Complaint phase B. Discovery phase C. Decision phase D. Trial phase

B. Discovery phase

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? A. Assessing the current health status of the client B. Explaining the operative procedure, risks, and benefits C. Reviewing preoperative laboratory test results D. Ensuring that a signed surgical consent form was completed

B. Explaining the operative procedure, risks, and benefits

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray. B. Have the client wear a mask. C. Notify the x-ray department that the client requires airborne precautions. D. Wear a filtration mask and gloves during transport.

B. Have the client wear a mask.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? A. Document what the nurse believes was the cause of ulcer development. B. Include any relevant statements the client made about the ulcer. C. Document in the client's medical record that she completed an incident report. D. Question the charge nurse about care deficits that might have contributed to the ulcer's development.

B. Include any relevant statements the client made about the ulcer.

A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? A. Vigorously rub the skin following a decontamination shower. B. Initiate seizure precautions. C. Provide respiratory support with a plastic oral airway. D. Prepare to administer amyl nitrate.

B. Initiate seizure precautions.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90° angle to the bed. B. Lock the wheels of the bed and the wheelchair. C. Acquire the help of several people to lift the client. D. Elevate the bed to a position of comfort for the nurse.

B. Lock the wheels of the bed and the wheelchair.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism B. Nonmaleficence C. Fidelity D. Veracity

B. Nonmaleficence

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? A. Remind the client that a signed informed consent form is a legally binding document. B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. C. Inform the surgical team to cancel the client's surgery. D. Proceed with preparation of the patient for the surgical procedure.

B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A. Weigh the second client. B. Obtain vital signs for both clients. C. Administer pain medication to the first client. D. Change the dressings of both clients.

B. Obtain vital signs for both clients.

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) A. Provide discharge instructions to a confused client's spouse. B. Obtain vital signs from a client who is 6 hr postoperative. C. Administer a tap-water enema to a client who is preoperative. D. Initiate a plan of care for a client who is postoperative from an appendectomy. E. Catheterize a client who has not voided in 8 hr.

B. Obtain vital signs from a client who is 6 hr postoperative. C. Administer a tap-water enema to a client who is preoperative. E. Catheterize a client who has not voided in 8 hr.

An assistive personnel (AP) reports to the nurse that a client who returned to the unit following an abdominal hysterectomy has a dressing which is saturated with blood. Which of the following tasks should be delegated to the AP? A. Changing the abdominal dressing B. Obtaining vital signs C. Palpating for possible bladder distention D. Observing the incisional site

B. Obtaining vital signs

A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? A. Document the bruises in the client's chart. B. Report the findings to a supervisor. C. Provide the client with a crisis hotline number. D. Discuss respite care with the client's family.

B. Report the findings to a supervisor.

A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager? A. Reports routinely include the client's hospital number. B. Reports routinely omit the names of witnesses to the occurrence. C. Reports routinely list the identification number of any equipment involved. D. Reports routinely are completed within 24 hr after the incident.

B. Reports routinely omit the names of witnesses to the occurrence.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? A. Instruct the client about home disposal of contaminated dressings. B. Schedule a follow-up visit by a home health nurse for dressing changes. C. Provide a dietary list of foods which promote wound healing. D. Establish a follow-up appointment with the client's provider.

B. Schedule a follow-up visit by a home health nurse for dressing changes.

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? A. Make a copy of the incident report for the provider. B. Submit the incident report to the risk manager. C. Place the incident report in the client's chart. D. Document in the chart that an incidence report has been filed.

B. Submit the incident report to the risk manager.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? A. The AP's ability to prioritize B. The AP has the knowledge and skill to perform the task C. The AP's rapport with clients D. The AP's ability to complete the task without assistance

B. The AP has the knowledge and skill to perform the task

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? A. The client's partner B. The client C. The client's daughter, who is the primary caregiver D. The client's son, who has a durable power of attorney

B. The client

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A. The client cannot travel by air due to security screening. B. The client should hold his cell phone on the side opposite the ICD. C. The client should avoid the use of small electric devices. D. The client can carry his ICD in a small pocket.

B. The client should hold his cell phone on the side opposite the ICD.

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. B. The purpose of medication reconciliation is to prevent adverse medication reactions. C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.

B. The purpose of medication reconciliation is to prevent adverse medication reactions.

A community health nurse is providing a community education program about disaster preparedness. Which of the following should the nurse recommend that clients include in their family's disaster readiness supply kit or "go bag"? (Select all that apply.) A. Pencil and paper B. Whistle C. Antibiotics D. Copies of insurance cards E. Household bleach

B. Whistle C. Antibiotics E. Household bleach

A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)? A. "HICS ensures that necessary antibiotics and antidotes are available." B. "HICS is focused on having multidisciplinary responders available." C. "HICS identifies facility responsibilities and channels of reporting." D. "HICS provides additional responders when needs exceed the ability of local or state agencies."

C. "HICS identifies facility responsibilities and channels of reporting."

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? A. "It is time to sign the consent so your treatment can begin." B. "I would not have this type of surgery if I were you." C. "Have you discussed other treatments with your provider?" D. "I can inform the surgeon you do not want the surgery."

C. "Have you discussed other treatments with your provider?"

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? A. "I can change who I designate as my health care proxy at any time." B. "If I become incapacitated, end-of-life choices will be made by my proxy." C. "I have to choose a family member as my health proxy." D. "The health care proxy does not go into effect until I am incapable of making decisions."

C. "I have to choose a family member as my health proxy."

A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? A. "I feel you are being inconsiderate of the other team members." B. "I have to let the director of nursing know about this situation." C. "I need to talk to you about the unit policies regarding client assignments." D. "You always get your choice of assignment and don't work your fair share."

C. "I need to talk to you about the unit policies regarding client assignments."

A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "I should wait to empty my client's drainable colostomy until it is three-fourths full." B. "I should delegate providing closed irrigation to the assistive personnel (AP)." C. "I should encourage clients to receive an annual flu immunization." D. "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care."

C. "I should encourage clients to receive an annual flu immunization."

A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "I should wait to empty my client's drainable colostomy until it is three-fourths full." B. "I should delegate providing closed irrigation to the assistive personnel (AP)." C. "I should encourage clients to receive an annual flu immunization." D. "I should recommend that my clients who have an established tracheostomy use sterile technique at home to provide ostomy care."

C. "I should encourage clients to receive an annual flu immunization."

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate? A. "You should think about how you make others feel when you lose your temper." B. "I will help you with this procedure instead of the staff nurse." C. "It must be very frustrating when you don't have want you need to perform the procedure." D. "If you let us know ahead of time that you plan to perform a procedure, we could do a better job of having the supplies available."

C. "It must be very frustrating when you don't have want you need to perform the procedure."

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse? A. "Let's talk about something else." B. "Whether or not I am a good lover is irrelevant." C. "Speaking to me like that makes me uncomfortable." D. "You need to lower your voice. Others can hear you."

C. "Speaking to me like that makes me uncomfortable."

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? A. Glasgow results B. Intracranial pressure readings C. Code status D. Plan of care changes for upcoming shift

C. Code status

A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "The nurse relinquishes accountability for client outcomes when care is delegated to an AP." B. "The AP can provide client education about how to perform basic self-care to the client." C. "The nurse should consider the AP's level of experience when making delegation decisions." D. "The AP can re-delegate a task to another AP who has similar work experience."

C. "The nurse should consider the AP's level of experience when making delegation decisions."

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? A. A client who needs assistance with a bath B. A client requesting a referral for home health services C. A client asking about his PCA pump that contains morphine D. A client who has questions about his new prescription

C. A client asking about his PCA pump that contains morphine

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. B. A staff member does not show up to work her assigned shift. C. A client discovers that his dentures are missing. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.

C. A client discovers that his dentures are missing.

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? A. A client who has a splinted open fracture of left medial malleolus B. A client who has a massive head injury and is experiencing seizures C. A client who has severe respiratory stridor and a deviated trachea D. A client who has a small circular partial-thickness burn of the left calf

C. A client who has severe respiratory stridor and a deviated trachea Rationale: A client who has severe respiratory stridor and a deviated trachea is unstable. This client is triaged as emergent, and requires immediate attention to survive. This client has manifestations of a tension pneumothorax and airway obstruction. Therefore, this client is the highest priority for the nurse to assess.

A nurse is planning to assign obtaining the vital signs of postoperative clients to an assistive personnel (AP). The nurse should assign obtaining vital signs for which of the following clients? A. A client who is 3 hr postoperative following a thyroidectomy B. A client who is 3 hr postoperative following an abdominal hysterectomy C. A client who is 3 days postoperative following gastric bypass surgery D. A client who is 3 days postoperative following a craniotomy

C. A client who is 3 days postoperative following gastric bypass surgery

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN? A. A client who has terminal end-stage renal disease B. A client who has acute pancreatitis C. A client who is one-day postoperative following a total abdominal hysterectomy D. A client who had a stroke and is to be admitted

C. A client who is one-day postoperative following a total abdominal hysterectomy

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A. An adolescent female client who is belligerent and has slurred speech B. A toddler who has a laceration on his forehead and is screaming C. A middle adult male who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn of his face and arms

C. A middle adult male who is diaphoretic and reports epigastric pain

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min B. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication

C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conflict resolution? A. Use aggressive communication skills. B. Assist the provider in identifying alternative solutions. C. Address the situation as soon as possible. D. Foster closed communication.

C. Address the situation as soon as possible.

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work, but are not exhibiting manifestation of illness. Which of the following is the appropriate action for the nurse to take? A. Place the clients in isolation. B. Initiate client decontamination. C. Administer antibiotic therapy. D. Treat clients with an antitoxin.

C. Administer antibiotic therapy.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? A. Situation B. Background C. Assessment D. Recommendation

C. Assessment

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of over delegation? A. Assigning two assistive personnel (AP) to ambulate all clients B. Assigning a new graduate nurse to perform a wet-to-dry dressing change C. Assigning the most efficient AP to perform glucometer monitoring for each client D. Assigning the most competent RN to perform a central line dressing change

C. Assigning the most efficient AP to perform glucometer monitoring for each client

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) A. Raise all side rails on the client's bed. B. Obtain a prescription to restrain the client PRN. C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg.

C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg.

A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take? A. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. B. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. C. Explain the risk the client faces if she leaves the facility.

C. Explain the risk the client faces if she leaves the facility.

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? A. Provide professional counseling for staff members. B. Change policies for staff observation of clients who are suicidal. C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. D. Give the family an opportunity to talk about their feelings.

C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.

A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict? A. Implement a resolution. B. Brainstorm solutions. C. Identify the problem. D. Evaluate the results.

C. Identify the problem.

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Perform wound irrigation for a client. B. Evaluate pain relief for a client following the administration of a pain medication. C. Measure and record intake and output for a client. D. Teach a client about low-sodium foods.

C. Measure and record intake and output for a client.

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)? A. Application of antibiotic ointment to the arm of a client who has dermatitis. B. Obtaining medical history information from a stable client who is being admitted. C. Monitoring vital signs of a client who had an appendectomy 12 hr ago. D. Removal of the nasogastric tube of a client who has been receiving enteral feedings.

C. Monitoring vital signs of a client who had an appendectomy 12 hr ago.

A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form? A. Extended family B. Blended family C. Nuclear family D. Intergenerational family

C. Nuclear family

An assistive personnel (AP) contacts a nurse manager and reports that on the last shift a nurse seemed distracted and that a client reported that the nurse smelled of alcohol. The AP alleges that the nurse was drinking alcohol during the shift. Which of the following actions should the nurse manager take first? A. Confront the nurse. B. Refer the nurse to the state board of nursing diversion program. C. Perform an investigation into the facts surrounding the incident. D. Develop a disciplinary plan for the nurse.

C. Perform an investigation into the facts surrounding the incident.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Remove the bottle cap. B. Pick up the bottle with the label facing toward the palm. C. Perform hand hygiene. D. Pour 1 to 2 mL into a receptacle. E. Pour the solution onto the gauze. F. Place the bottle cap face-up on a clean surface.

C. Perform hand hygiene. A. Remove the bottle cap. F. Place the bottle cap face-up on a clean surface. B. Pick up the bottle with the label facing toward the palm. D. Pour 1 to 2 mL into a receptacle. E. Pour the solution onto the gauze.

A nurse in the cardiac catheterization lab implements a new procedure for achieving hemostasis of the cardiac catheter insertion site. Which of the following is a distinguishing characteristic of a new standard of care? A. Achievable B. Measurable C. Predetermined D. Objective

C. Predetermined

A nurse is an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit? A. Availability of resources, such as fire extinguishers B. Nursing staff ratios C. Quality of nursing care provided D. Length of facility stay for a cohort of clients

C. Quality of nursing care provided

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents? A. Chemical B. Anthrax C. Radiologic D. Sarin

C. Radiologic

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN? A. Complete an admission assessment for a client who has COPD. B. Measure I&O for a client who has an indwelling urinary catheter. C. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. D. Develop a plan of care for a client who has cholecystitis.

C. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse? A. Transporting a client who experienced a stroke 72 hr ago to the radiology department B. Providing a back rub to a client who has right-sided paralysis C. Removing and cleaning the cannula of a client who has a new tracheostomy D. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm

C. Removing and cleaning the cannula of a client who has a new tracheostomy

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criteria the RN considers when delegating? A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN

D. State Nurse Practice Act for the LPN

A charge nurse has assigned a group of clients to a newly licensed practical nurse (LPN). The charge nurse observes the LPN chatting sociably with peers, learns that the LPN left the unit without communicating the absence, and receives reports from clients about lack of care by the LPN. Which of the following is an appropriate action by the charge nurse? A. Review the LPN's personnel file. B. Discuss the LPN's behavior with other nurses on the unit. C. Review the LPN's assignment in relation to other nurses on the unit. D. Reassign some of the nurse's client care to assistive personnel.

C. Review the LPN's assignment in relation to other nurses on the unit.

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? A. Provide an inservice on medication administration to all the nurses. B. Require staff nurses to demonstrate competency by passing a medication administration examination. C. Review the events leading up to each medication administration error. D. Develop a quality improvement program for nurses involved in medication administration errors.

C. Review the events leading up to each medication administration error.

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? A. The client who requires frequent ambulation B. The client who is in protective isolation C. The client who is actively dying and requires IV pain medication D. The client who is 3 days postoperative and requires a dressing change

C. The client who is actively dying and requires IV pain medication

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include? A. The nurse caring for the client at the time of death requests organ donation. B. Donation costs are the responsibility of the donor's family and estate. C. The nurse may serve as a witness to informed consent for organ donation. D. Clients are placed on artificial life support before organ and tissue donation can occur.

C. The nurse may serve as a witness to informed consent for organ donation.

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure? A. The AP ties the straps of the restraints in a double knot. B. The AP ties the restraints to the side rails C. The padding of the restraints is against the client's bony prominences. D. The nurse can insert one finger between the client's wrist and the restraint.

C. The padding of the restraints is against the client's bony prominences.

A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? A. Return any fresh linen not used for a client to the linen supply area. B. Use double bagging to remove soiled linen from the client's room. C. Tie linen bags securely at the top. D. Fill linen bags with as much soiled linen as possible.

C. Tie linen bags securely at the top.

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? A. Preventing cross-contamination of clients B. Performing concise client assessment C. Transferring a client to the discharge location D. Maintaining a client tracking system

C. Transferring a client to the discharge location

A new graduate nurse is making staff assignments. He assumes responsible for all clients needing IV medications and high-level assessment skills and gives responsibility for the remaining clients to other personnel. This is an example of which error in delegation? A. Adopting familiar delegation patterns B. Failure to provide delegation control C. Underdelegating D. Unclear communication

C. Underdelegating

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. Hold gauze packages 7.6 cm (3 in) above the sterile field. B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field. C. Use sterile forceps to move the sterile items on the sterile field. D. Position the wrapped package on the bedside table so the outer flap opens towards her.

C. Use sterile forceps to move the sterile items on the sterile field.

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.) A. Establish that the client is able to pay for the surgical procedure. B. Explain the surgical procedure to the client. C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary.

C. Validate the signature is authentic. D. Verify the client understands the surgical procedure. E. Confirm that the consent is voluntary.

A nurse manager is planning to discipline a nurse after discovering that the nurse was discourteous to a client. Which of the following disciplinary steps should the nurse manager take first? A. Written admonishment B. Suspension from work C. Verbal admonishment D. Involuntary dismissal

C. Verbal admonishment

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? A. Complete an incident report. B. Request the risk manager obtain consent for HIV testing from the client. C. Wash the site of injury with soap and water. D. Consent to postexposure treatment with antiretroviral medications.

C. Wash the site of injury with soap and water.

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? A. Discussing advance directives with the client and the client's family B. Providing comfort care measures to the client C. Withholding a dose of narcotic pain medication when the client has respiratory depression D. Allowing the client's family unlimited visitation at the time of death

C. Withholding a dose of narcotic pain medication when the client has respiratory depression

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? A. A client who is a 1 day postpartum after a late term miscarriage B. A client who had a bilateral tubal ligation 12 hr previously C. A client who is 4 days postpartum and has mastitis D. A client admitted 1 hr ago for an ectopic pregnancy

D. A client admitted 1 hr ago for an ectopic pregnancy

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. A client who has pertussis C. A client who has streptococcal pharyngitis D. A client who has measles

D. A client who has measles

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? A. Utility B. Paternalism C. Justice D. Nonmaleficence

D. Nonmaleficence

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion? A. "Clients should be given medications even if they refuse them." B. "The laws regarding restraints are different for clients who are admitted involuntarily." C. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary." D. "Clients who are involuntarily admitted have the right to informed consent."

D. "Clients who are involuntarily admitted have the right to informed consent."

A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN? A. "I do not know how to make the remote control work." B. "Do you know when I will be going home?" C. "My dressing was changed earlier this morning." D. "I have not received any of my medications today."

D. "I have not received any of my medications today."

A charge nurse is preparing to introduce a new type of infusion pump to the unit nursing staff. Which of the following statements by the charge nurse displays her as a change agent? A. "I want to let everyone know today we start using a new infusion pump." B. "It is never too late to learn how to use a new infusion pump." C. "I think sometime this week we will have an in-service on the new infusion pump." D. "I want to remind everyone about the in-service on using the new infusion pump."

D. "I want to remind everyone about the in-service on using the new infusion pump."

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate? A. "Tell me why you feel hopeless." B. "I am sure these feelings will pass once you go home." C. "If I were you, I would ask for a referral to hospice care." D. "Tell me what you understand about your illness."

D. "Tell me what you understand about your illness."

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching? A. "You should hold the cane in your weak hand when ambulating." B. "You should advance the cane 12 to 14 inches before taking a step." C. "You should advance your weak leg forward to the cane, then move your strong leg." D. "The cane's height should be the same as the distance from the floor to the crest of your hip bone."

D. "The cane's height should be the same as the distance from the floor to the crest of your hip bone."

A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make? A. "I will ask the nursing supervisor to obtain the medical records for you." B. "The health care provider will share this information with you." C. "The ethics committee will need to approve this request for you." D. "The client must provide permission to share the records with you."

D. "The client must provide permission to share the records with you."

A nurse is teaching the assistive personnel (AP) to set limits on a client's manipulative behavior after the nurse has reviewed the APs performance of a delegated task. Which of the following responses by the AP indicates further teaching is needed? A. "Consistency among staff is important." B. "I will set limits each time I see a dysfunctional behavior." C. "I understand that limit-setting counteracts resistance." D. "The goal for the client is to ask directly for what he wants."

D. "The goal for the client is to ask directly for what he wants."

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients? A. A child who is experiencing sickle cell crisis B. A child who has streptococcal pharyngitis C. A child who has a head injury D. A child who has a new diagnosis of type 1 diabetes mellitus

D. A child who has a new diagnosis of type 1 diabetes mellitus

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority? A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

A nurse manager is preparing an inservice program about managing conflict for the nurses on the unit. The nurse manager should identify which of the following examples as interpersonal conflict? A. Nurses on the unit disagree about what time of day daily client weights should be obtained B. A nurse is uncertain about joining a professional nursing organization C. A nurse who just lost his spouse does not want to be assigned to care for a terminally ill client D. An experienced nurse is uncivil to a newly licensed nurse

D. An experienced nurse is uncivil to a newly licensed nurse

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? A. A client who has previously undergone a procedure that is to be performed for a second time B. A client who has been educated on treatment options and chooses alternative treatments C. A client who makes an informed decision not to participate in chemotherapy treatment D. An older adult client who has no family and is uncertain about moving to assisted living

D. An older adult client who has no family and is uncertain about moving to assisted living

A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take? A. Take the specimen to the laboratory. B. Report the AP to the charge nurse. C. Complete an incident report. D. Ask the AP about her concerns with the assignment.

D. Ask the AP about her concerns with the assignment.

A nurse is planning care at the beginning of a shift. Which of the following tasks could a nurse assign to assistive personnel (AP)? A. Removing a client's nasogastric tube B. Inserting indwelling urinary catheter C. Providing a client's postmortem care D. Assisting the client to select a low-residue diet

D. Assisting the client to select a low-residue diet

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? A. Assault B. False imprisonment C. Negligence D. Battery

D. Battery

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? A. Collect a stool sample for ova and parasites from a school-age child B. Engage a toddler in play. C. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma. D. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

D. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

A nurse is transcribing a client's medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions should the nurse take? A. Clarify the prescription with the client's family. B. Interpret the prescription based on the client's health history. C. Ask the pharmacist for clarification of the prescription. D. Contact the provider to clarify the prescription.

D. Contact the provider to clarify the prescription.

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management? A. Avoiding B. Competing C. Compromising D. Cooperating

D. Cooperating

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? A. Ensuring the charge nurse is available to witness the client's signature on the consent form B. Explaining the risks involved with the procedure C. Discussing alternate treatment options D. Determining the client's level of understanding about the procedure

D. Determining the client's level of understanding about the procedure

A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following? A. Slander B. Invasion of privacy C. Defamation of character D. False imprisonment

D. False imprisonment

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which of the following groups? A. The client's immediate family members B. Clergy affiliated with the facility C. The facility's administrators D. Health care team members caring for the client

D. Health care team members caring for the client

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following does the charge nurse consider? A. The comfort level of the nurses in delegating tasks to assistive personnel (AP). B. Personal comfort level in making the assignments. C. Social relationships between nurses working the oncoming shift. D. Information needed by nurses to perform the assigned tasks.

D. Information needed by nurses to perform the assigned tasks.

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles? A. Veracity B. Autonomy C. Fidelity D. Nonmaleficence

D. Nonmaleficence

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? A. Counsel the provider to determine the cause of the substance abuse. B. Encourage clients to change to a different provider. C. Inform the state medical board for an immediate investigation. D. Notify the nursing supervisor of the concerns.

D. Notify the nursing supervisor of the concerns.

Which of the following examples display interpersonal conflict? A. Nurses on the day and night shift are conflicting regarding who should do client daily weights. B. Nurses throughout the hospital disagree on having 8-hour shifts or 12-hour shifts. C. Nurse Jones is deciding between going to a professional meeting or attending a play. D. Nurse Lee is professionally threatened by Nurse Doe.

D. Nurse Lee is professionally threatened by Nurse Doe.

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? A. Members of the Federal Emergency Management Agency (FEMA) B. Responding law enforcement officers C. Representatives from the American Red Cross D. Nurses and other emergency medical personnel

D. Nurses and other emergency medical personnel

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused

D. Observing a postoperative client who is confused

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused

D. Observing a postoperative client who is confused

The RN on a medical-surgical unit is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)? A. Developing the plan of care for a client with an amputation B. Evaluating the outcomes of a new postoperative client C. Analyzing data to identify issues for a client with uncontrolled diabetes D. Performing crutch walking of a client following knee replacement surgery

D. Performing crutch walking of a client following knee replacement surgery

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? A. Shakes the soiled linen to remove any toilet paper remnants B. Places the soiled linen on the floor before bagging it C. Holds the soiled linen against her body while carrying it to the linen bag D. Places clean linen that touched the floor in the soiled linen bag

D. Places clean linen that touched the floor in the soiled linen bag

A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take? A. Assess the AP's ability to follow the client's teaching plan. B. Determine the social skills of the AP. C. Evaluate the ability of the AP to work with peers. D. Provide a clear description of the task to the AP.

D. Provide a clear description of the task to the AP.

A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take? A. Inform the staff member of her appraisal time for that day prior to change-of-shift report. B. Schedule the appraisal interview as early in the shift as possible. C. Provide a chair directly across the desk for the staff member to sit in. D. Provide the staff member with a copy of the appraisal form in advance.

D. Provide the staff member with a copy of the appraisal form in advance.

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? A. Wound drainage for culture B. Urine from an indwelling catheter C. Blood for PaCO2 D. Random stool specimen

D. Random stool specimen

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire. D. Rescue the clients.

D. Rescue the clients. A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire.

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? A. Hospice care B. Restorative care C. Mental health care D. Respite care

D. Respite care

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? A. Right circumstances B. Right communication C. Right person D. Right supervision

D. Right supervision

A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change? A. Assess the problem. B. Use tactics to alert staff nurses that a change is needed. C. Evaluate the effectiveness of the change. D. Set a target date.

D. Set a target date.

A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of the following agents should the nurse plan to administer a vaccine following exposure? A. Anthrax B. Botulism C. Plague D. Smallpox

D. Smallpox

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? A. Droplet B. Contact C. Airborne D. Standard

D. Standard

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse allows the client to rest in a supine position during feeding.

D. The nurse allows the client to rest in a supine position during feeding.

A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? A. The nurse uses clean gloves when discontinuing a client's intravenous infusion. B. The nurse empties a client's drainable colostomy pouch when it is one-third full. C. The nurse uses the client's telephone number as one form of identification when administering medications to a client. D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.

D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider? A. The most experienced nurse receives the more complex clients B. Personal comfort level in making the assignments C. Social relationships between nurses working the oncoming shift D. The physiologic status of the clients on the unit

D. The physiologic status of the clients on the unit

A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? A. Ensure that 1 finger breadth of space is between the client's wrists and the restraint. B. Secure the restraints to the side rails. C. Remove the restraint to check integrity of the skin every 4 hr. D. Tie the restraint using a quick release knot.

D. Tie the restraint using a quick release knot.