Leadership Mid-Term Class Questions
The distribution of nurses to areas of "most need" in the time of a nursing shortage is an example of: A.Utilitarianism theory B.Deontological theory C.Justice D.Beneficence
C. Justice
A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? A.Temperature B.Blood pressure C.Respirations D.Urinary output
Correct Answer: C - Respirations
The nurse is caring for a client with severe menstrual bleeding and abdominal cramps. Which task is appropriate to be delegated to the licensed practical nurse (LPN)? 1.Evaluation of the pain status 2.Administration of oral analgesics 3.Administration of intravenous replacement fluids 4.Assessment of blood reports for hemoglobin levels
2.Administration of oral analgesics
What nursing actions could result in malpractice? Select all that apply. A. Reassessing a patient in restraints every 4 hours instead of every 2 hours as ordered. B. Forgets to complete a head to toe assessment on a newly admitted client. C. Does not administer a medication because the client's chart states an allergy to it. D. Questions a physician's order about a medication dose. E. Administers a parenteral medication to a combative client trying to harm others without a physician's order.
Answers: A, B, and E
A nurse is preparing to receive a 65 year old patient in the PACU after abdominal surgery. What should the nurse assess first? A.Level of consciousness B.Pain level C.Respiratory status D.Capillary refill
Correct Answer: C- Respiratory status
A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action? A. Administer the medication B. Notify the prescriber C. Call the pharmacist. D. Refuse to administer the medication.
Answer: B
As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day? A.36-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy B.63-year-old with osteomalacia who is being discharged to a long-term care facility C.69-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed D.73-year-old with Paget disease who has just returned from surgery for total knee replacement
D. 73-year-old with Paget disease who has just returned from surgery for total knee replacement
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. A client complaining of muscle aches, a headache, and history of seizures B. A client who twisted her ankle when rollerblading and is requesting medication for pain C. A client with a minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
When signing a form as a witness, your signature shows that the client: A.Is fully informed and is aware of all the consequences B.Was awake and fully alert and not medicated with narcotics. C.Wass free to sign without pressure D.Has signed that form and the witness saw it being done.
D. Has signed that form and the witness saw it being done
What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client? ±1. Monitoring clinical manifestations ±2. Collecting the data to be used in the assessment of the IV side ±3. Administering IV fluids and medications ±4. Evaluating the client for clinical manifestations
±1. Monitoring clinical manifestations
A charge nurse is leading an orientation of new employees. Which statements made by the charge nurse demonstrate appropriate delegation? Select all that apply. ±1. "An LPN can delegate dressing changes to the unlicensed assistive personnel (UAP) ±2. "An LPN can administer immunizations to a child less than 2 years of age" ±3. "An LPN can add a dose of chemotherapy to an existing IV infusion" ±4. "An experienced UAP can help transfer stable clients using a mechanical lift" ±5. "A UAP can assess the client 15 minutes after a blood transfusion"
±2. "An LPN can administer immunizations to a child less than 2 years of age" ±4. "An experienced UAP can help transfer stable patients using a mechanical lift"
You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? ±1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire. ±2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts. ±3. 45-year-old with infected with partial-thickness back and chest burns who has a dressing change scheduled. ±4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints.
±3. 45-year-old with infected with partial-thickness back and chest burns who has a dressing change scheduled.
After the change of shift, you are assigned the following patients. Which patient should you assess first? A.A 60-year old patient on a ventilator who needs a sterile sputum specimen sent to the lab. B.A 70-year old patient with pneumonia who needs to be started on IV antibiotics. C.A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90%. D.A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
Correct Answer: D The 50-year old who has asthma and is complaining of shortness of breath after taking his bronchodilator.
Which interventions are within the scope of a licensed practical nurse (LPN)? 1.Client teaching 2.Ambulating the client 3.Interpreting lab data 4.Assisting the client with bathing 5.Administering intramuscular medications
2.Ambulating the client 4.Assisting the client with bathing 5.Administering intramuscular medications
A nurse triages clients arriving to the hospital after a mass casualty. What client is correctly classified? a.A 35 year old female with severe chest pain: red tag b.A 55 year old women with a minor scalp laceration: black tag c.A 88 year old man with severe chest pain and shortness of breath: yellow tag d.A 42 year old man with an open fracture and distal pulses: green tag
A is the correct answer
A large number of patients arrive to the ED following a mass casualty incident. The nurse identifies the clients with which injuries as yellow tags (class II)? (SATA) a. Partial-thickness burns on hands and feet b. Head injury and difficult to arouse c. Bruising and pain in the right lower abdomen d. Small pieces of shrapnel embedded in both eyes e. Open fractures of both legs with no distal pulses f. Neck injury and numbness of both legs
A, C, D, F are the correct answers
Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A.American Nurses Association's (ANA's) Code of Ethics B.Nurse Practice Act (NPA) written by state legislation C.Standards of care from experts in the practice field D.Good Samaritan laws for civic guidelines
A. American Nurses Association's (ANA's) Code of Ethics
When the nurse described the client as "the nasty old man in 354," the nurse is exhibiting which ethical dilemma? A.Gender Bias and ageism B.HIPPA violation C.Beneficence D.Code of ethics violation
A. Gender Bias and ageism
Which actions should the nurse take during a tornado? Select all that apply A. Move beds away from windows B. Open doors to client rooms C. Close windows and curtains D. Relocate ambulatory clients from the hallway back to their rooms. E. Place blankets over patients who cannot get out of bed
A. Move beds away from windows C. Close windows and curtains E. Place blankets over patients who cannot get out of bed
Nurses are bound by a variety of laws. Which description of a type of law is correct? A.Statutory law is created by elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA). B.Regulatory law includes prevention of harm for the public and punishment for those laws that are broken. C.Common law protects the rights of the individual within society for fair and equal treatment. D.Criminal law creates boards that pass rules and regulations to control society.
A. Statutory law is created by elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA).
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? Select all that apply. A.A 35-year-old female with severe chest pain: red tag B.A 42-year-old male with full thickness body burns: green tag C.A 55-year-old female with a scalp laceration: black tag D.A 60-year-old male with an open fracture with distal pulses: yellow tag E.An 88-year-old male with shortness of breath and chest bruises: green tag
A.A 35-year-old female with severe chest pain: red tag D.A 60-year-old male with an open fracture with distal pulses: yellow tag
You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? A.Assisting the patient with oral hygiene B.Observing the patient's response to feedings C.Facilitating expression of grief or anxiety D.Initiating daily weighings
A.Assisting the patient with oral hygiene
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A.Auscultate breath sounds B.Administer medications by metered-dose inhaler C.Complete in-depth admission assessment D.Initiate the nursing care plan E.Evaluate the patient's technique for using metered-dose inhalers
A.Auscultate breath sounds B.Administer medications by metered-dose inhaler
Emergency Medical Services (EMS) brings a large number of clients into the emergency room following a mass casualty event. The nurse identifies the clients with which injuries with yellow tags? Select all that apply. A.Partial-thickness burns covering both legs B.Open fractures of both legs with absent pedal pulses C.Neck injury and numbness of both legs D.Small pieces of shrapnel embedded in both eyes E.Head injury and difficult to arouse F.Bruising and pain in the right lower abdomen
A.Partial-thickness burns covering both legs C.Neck injury and numbness of both legs D.Small pieces of shrapnel embedded in both eyes F.Bruising and pain in the right lower abdomen
The RN is informed by the NA that the client, hospitalized last evening with chest pain, plans to leave right now because the pain is gone and "nobody has done anything anyway". Which is the nurse's best action? 1. Thank the NA for the information and then call the client's doctor regarding the situation 2. Tell the NA that the client has the right to leave and send the NA to help the client pack 3. Talk with the client to discuss the client's concerns and explain the plan of care 4. Tell the NA to inform the client that it is unsafe to leave; the RN will see the client shortly
Answer: 3
A 78-year-old client is brought to your unit at the hospital with several activities included in his plan of care. He was admitted with a diagnosis of anemia due to possible gastrointestinal bleeding. Which of the following activities can you delegate to the experienced UAP? A.Obtaining a stool specimen for hemoccult testing slides B.Having the patient sign a consent form for a colonoscopy C.Administering prescribed polyethylene glycol electrolyte solution (GoLYTELY) D.Checking the patient's chart for allergies to contrast dye or shellfish
ANS: A. An experienced UAP will be taught the proper technique to obtain a fecal specimen for a hemoccult testing slide because it is a common test performed in the hospital setting.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours.
ANS: A. Assisting the patient to sit up on the side of the bed.
Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to: A. Role modeling behaviors of the preceptor B. The philosophy of the new nurse's school of nursing C. The orientation provided to the new nurse D. Lack of trust in the members of the healthcare team
ANS: D. Lack of trust in the members of the healthcare team.
You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP? A. Identifying environmental factors that increase risk for falls B. Monitoring gait, balance, and fatigue level with ambulation C. Collaborating with the physical therapist (PT) to provide the patient with a walker D. Assisting the patient with ambulation to the bathroom and in the halls
Ans: D Assisting with activities of daily living (ADLs) is within the scope of the UAP's practice.
A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Instruct personnel to don personal protective equipmentB. B. Direct the clients to the cold or clean zone for immediate treatment C. Immediately remove other clients and visitors from the area D. Measure vital signs and auscultate lung sounds E. Direct the clients to the decontamination area
Answer (E): Direct clients to the decontamination area.
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? A. Provide water and healthy snacks for energy throughout the event. B. Schedule 16-hour shifts to allow for greater rest between shifts. C. Encourage counseling upon deactivation of the emergency response plan. D. Assign staff to different roles and units within the medical facility.
Answer: (A): Provide water and healthy snacks for energy throughout the event.
Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her? A. Triage B. Ambulatory section C. Psychiatric care D. Trauma team
Answer: (B) Ambulatory Section
Which amount of time is appropriate for a nurse to spend triaging each client during a mass casualty accident? A. Less than 10 seconds B. Less than 15 seconds C. Less than 30 seconds D. Less than 60 seconds
Answer: (B) Less than 15 seconds
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? A. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. B. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. C. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. D. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
Answer: (D) Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
The client who is hard of hearing and primarily speaks German is being discharged home. Which action should be the nurse's priority when preparing to teach the client about newly prescribed medications? 1. Determine the client's literacy level for both German and English 2. Obtain literature about the medications written in German and English 3. Determine if there is another person who should be taught instead of the client 4. Ask the NA who also speaks German to review the information with the client
Answer: 1
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, "We were running around outside the school and he got hit in the abdomen with a stick!" Which statement should be a priority? 1."He has a family history of diabetes, so he requires attention now" 2."He pulled the stick out because it was too painful for him" 3."The stick was filthy and muddy" 4."There was plenty of blood so packed three gauzes inside the wound"
Answer: 2
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? 1.Irregular apical pulse 2.Ecchymosis in the flank area 3.A deviated trachea 4.Unequal pupils
Answer: 3
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area? 1.Notify the ED physician 2.Set the client on continuous electrocardiographic monitoring 3.Place intravenous (IV) access 4.Supplemental oxygen via nasal cannula
Answer: 4
The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? Select all that apply A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement B. Advise a client's transport technician, "this client has metastatic breast cancer and must be moved very carefully due to fragile bones" C. Asks a client quietly "when were you diagnosed with diabetes?" during admission assessment in a semiprivate room with the privacy curtain in place between beds D. Explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record E. Writes a client's last name on a whiteboard hanging in the nurses' station on which scheduled procedures are logged
Answer: A, B, and D
Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: A. Consult a professional ethicist to ensure that the steps of the process occur in full B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma C. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion D. Ensure that the attending physician has written an order for an ethics consultation to support the ethics process
Answer: B- Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma
An adult client is newly admitted to the PACU from surgery. Which assessment finding should be the nurse's priority? A. The surgical site dressing has a scant amount of blood B. The client is sleeping but easily aroused when touched C. The client's respirations are 8 BPM D. The client's blood pressure is 110/68 mmHg
Answer: C
The nurse who works on night shift enters the medication room and finds a coworker inserting a needle into her arm. What is the most appropriate action by the nurse? A.Call security B.Call the police C.Call the nursing supervisor D.Lock the coworker in the medication room until help is obtained
Answer: C
The nurse's partner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate A. Because the nurse is an employee, access to the chart is allowed. B. The relationship with the client provides the nurse special access to the chart. C. Access to the chart requires a signed release form D. The nurse can ask the surgeon to discuss the outcome of the surgery.
Answer: C
A nurse manager is talking to a new hire RN about the duty of care by the nurse to the client. She begins to read the minimum requirements that define an acceptable level of care. These requirements are best located in: A.Federal guidelines and regulations in the Care Standards Act of 2000 B.Nursing Social Policy Statement C.State nurse practice acts, standards published by nursing professional organizations and specialty practice groups, and/or a facility's policy and procedure manuals D.Published standards by the American Nursing Association
Answer: C - State nurse practice acts, standards published by nursing professional organizations and specialty practice groups, and/or a facility's policy and procedure manuals
A primary care provider's orders indicated that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, which statement "best" illustrates the nurse fulfilling the client advocate role? A. "The doctor has asked that you sign the consent form." B. "Do you have any questions about the procedure?" C. "What were you told about the procedure you are going to have?" D. "Remember that you can change your mind and cancel the procedure."
Answer: C- "What were you told about the procedure you are going to have?"
The nurse notes that an advance directive is in the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case? A. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state B. A living will allows an appointed person to make health care decisions when the client is in an incapacitated state. C. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. D. The client cannot make changes in the advance directive once the client is admitted into the hospital.
Answer: C- A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure b. Ask the EMS team to sign the informed consent c. Transport the victim to the operating room for surgery d. Call the police to identify the client and locate the family.
Answer: C- Transport the victim to the operating room for surgery
Betty is making the patient assignments for the next shift. On her unit there are 2 RNs, 1 LPN, and 2 UAPs. Which patients will you assign to the LPN? Select all that apply A.A 68 year old male patient who is expected to be d/c home with IV antibiotic therapy B.A 25 year old female patient newly admitted with DKA C.A 75 year old male patient with dementia who has an ileostomy and scheduled tube feedings D.A 65 year old female patient who has an order to remove a foley catheter
Answers: C and D
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A.Evaluating the patient's complaint of chest pain B.Monitoring laboratory values for changes in oxygenation C.Assessing for symptoms of respiratory failure D.Auscultating the lungs for crackles
Correct Answer: D- Auscultating the lungs for crackles
The nurse is a first responder at the scene of an accident. Which victim should be attended to first? A. A victim in pain B. A victim with airway obstruction C. A victim who is confused D. A victim with anxiety
B. A victim with airway obstruction
A nurse threatens to discharge a patient immediately after the patient refuses a nasogastric tube insertion procedure. The hospital administrator decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? A.Malpractice B.Assault C.Negligence D.Battery
B. Assault
The patient's nursing diagnosis is "Fluid Volume Deficit r/t excessive fluid loss". Which action related to fluid management can be delegated to the UAP? A.Administering IV fluids as prescribed by the physician B.Providing straws and offering fluids between meals C.Developing a plan for added fluid intake over 24 hours D.Teaching family members to assist the patient with fluid intake
B. Providing straws and offering fluids between meals
A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? A. Pull the fire alarm on the unit B. Remove anyone who is in immediate danger C. Obtain a fire extinguisher and report to the fire area D. Close all windows and fire doors and await further instruction
B. Remove anyone who is in immediate danger
The nurse administered a unit of blood on the wrong client, which resulted in an anaphylactic reaction in the client. During the resuscitation, the nurse does not reveal that the wrong blood was given. Which moral principle was absent in the nurse's actions? A.Human dignity B.Veracity C.Autonomy D.Social justice
B. Veracity
A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? A. repositions side to side every 2 hours B. elevates the head of the bed 60 degrees C. auscultates the lung field every 4 hours D. encourages deep breathing exercises every 2 hours
B. elevates the head of the bed 60 degrees
A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? Select all that apply. A.Older adult in the medical decision unit for evaluation of chest pain B.Client who had open reduction and internal fixation of a femur fracture 3 days ago C.Client admitted last night with community-acquired pneumonia D.Infant who has a fever of unknown origin E.Client on the medical unit for wound care
B.Client who had open reduction and internal fixation of a femur fracture 3 days ago E.Client on the medical unit for wound care
What is the role of the nurse manager/leader during a code blue emergency? a.Initiating CPR b.Distribute code cart supplies and operate/monitor defibrillator c.Communicate with family, contact appropriate personnel, arrange patient transfer d.Direct the overall resuscitative efforts
C is the correct answer
The emergency department nurses receive a call that a tornado has hit locally resulting in numerous causalities. The victims will come to the ED. The nurse should take which initial action? A. Obtain additional supplies B. Prepare the triage room C. Activate the emergency response plan D. Call in additional staff
C. Activate the emergency response plan
A nurse walks into the medication room and sees a coworker using a syringe attached to a needle to inject himself with a clear liquid. What is the most appropriate action by the nurse? A.Call the police. B.Call the hospital security C.Call the nursing supervisor D.Lock the coworker in the medication room until help is obtained
C. Call the nursing supervisor
Which color tag should be given to "walking wounded" clients according to the disaster triage tag system? A. Red B. Black C. Green D. Yellow
C. Green
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disruptive sleep cycle. Which action should you delegate to the nursing assistant? A.Discuss weight loss strategies with the patient such as diet & exercise. B.Teach the patient how to set up the BiPAP machine before sleeping. C.Remind the patient to sleep on his side not his back. D.Administer medications to promote daytime wakefulness.
C. Remind the patient to sleep on his side not his back.
The nurse is the first responder after a tornado. Which victim should the nurse attend to first? A. A pregnant woman who is yelling, "My husband is not moving!" B. A young child who is screaming, "I want my mommy!" next to an adult family member C. A child who says, "My arm is bleeding so bad; it feels like it is going to fall off" D. A man who is crying because his wife is dead.
C. child who says "My arm is bleeding so bad; it feels like it is going to fall off"
A nurse cares for a clients during a community wide disaster drill. One of the clients asks, "Why are there individuals with black tags not receiving any care? How should the nurse respond? A."To do the greatest good for the greatest number of people, it is necessary to sacrifice some" B."Not everyone will survive a disaster, so it is best to identify those people early and move on" C."In a disaster, extensive resources are not used for one person as the expense of many others" D."With black tags, volunteers can identify those who are dying and give them comfort care"
C."In a disaster, extensive resources are not used for one person at the expense of many others"
The nurse is caring for four clients with different problems. Which client should be given care first? Client A - simple fracture Client B - pneumonia Client C - hemorrhage Client D - renal colic
Client C: Hemorrhage
You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post- op or pre- op for surgery. Which assessment finding requires further nursing action? A.Orange- colored urine in a patient who is taking pyridium and is post- op day 3 from a TURP. B.No stool excretion in a patient who is post- op day 2 from a colostomy. C.Shoulder pain in a patient who is post- op day 1 from a laparoscopic cholecystectomy. D.Pain rating that has decreased from a 10 to a 0 in a patient who is awaiting an appendectomy.
Correct Answer D: Pain rating that has decreased from a 10 to a 0 in a patient who is awaiting an appendectomy
A 40 year old female comes into the ED with complaints of weakness, dry mouth, and confusion. The patient has a PMH of type II diabetes and is believed to be in diabetic hyperosmolar syndrome (HHNS). What tasks can the RN delegate to the unlicensed assistive personnel (UAP)? SATA A.Obtain vital signs B.Obtain a blood glucose level C.Assess breath sounds D.Document intake and output E.Administer IV 0.9% NS
Correct Answer: A - Obtain Vital Signs, D - Document intake and output
You are caring for a patient with esophageal cancer. Which task can be delegated to the UAP? A.Assisting the patient with oral hygiene. B.Observing the patient's response to feedings. C.Facilitating expression of grief or anxiety. D.Initiating daily weighings.
Correct Answer: A- Assisting the patient with oral hygiene.
Nurse Taylor is working with a patient who has ARDS on a non-rebreather face mask, but his ABG's are showing poor oxygenation. What is the nurse's first priority of care for this patient? A.Perform endotracheal intubation and initiate mechanical ventilation B.Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth C.Administer Lasix 100mg IV push STAT D.Call a code for respiratory arrest
Correct Answer: A- Perform endotracheal intubation and initiate mechanical ventilation
The LPN reports to the nurse that the client's TPN infusion was inadvertently turned off 1 hour ago. In response to this finding, which statement to the LPN should be the nurse's priority? A."Please check the client's respiratory rate" B."Please check the client's blood sugar" C."Please check the client's blood pressure" D."Please check the client's level of consciousness"
Correct Answer: B "Please check the client's blood sugar"
The nurse gets pulled to a medical surgical floor and is assigned 4 patients. Which patient should the nurse see first? A.A 99 year old patient with UTI positive with E. Coli who is admitted because of a fall B.A 44 year old patient with severe anxiety and a GI bleed C.A 24 year old patient with new onset weakness.Past medical history of depression. D.A 67 year old patient with cough and chills that is negative for both covid-19 and the flu.
Correct Answer: B- the 44 year old patient with severe anxiety and a GI bleed needs to be seen first.
A nurse is getting report on a patient receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for the client? A.Readiness for enhanced learning B.Imbalanced nutrition, less than bodys requirements C.Risk for aspiration D.Diarrhea
Correct Answer: C- risk for aspiration is the correct answer
The charge nurse on duty is making assignments for the oncoming shift. There are 4 RNs, 1 LPN, and 2 UAPs. What patient should the charge nurse assign to the licensed practical nurse (LPN)? A.A 30 year old female patient with sickle cell disease and a scheduled blood transfusion for 0800. B.A 25 year old female patient newly admitted with exacerbation of Crohn's Disease. C.A 45 year old male patient being discharged home with necessary teaching about newly diagnosed type II diabetes. D.A 39 year old male patient 5 days post-op from bowel resection and on full liquid diet.
Correct Answer: D - A 39 year old male patient 5 days post-op from bowel resection and on full liquid diet.
Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated? A.Empty an ostomy bag B.Record patients vital signs C.Assist patient with ambulation D.Apply hydrocortisone cream to eczema on skin after giving the patient a bath
Correct Answer: D - Apply hydrocortisone cream to eczema on skin after giving the patient a bath.
Two hours after admitting the client to a post-surgical unit following a nephrectomy, the client states feeling nauseated. The nurse notes minimal drainage from the NG tube. Which action should the nurse take first? A.Immediately notify the HCP of the reduced NG returns B.Administer an antiemetic medication listed on the client's medication administration record C.Pull the NG tube out an inch to release it from suctioning against the wall of the stomach D.Irrigate the NG and check to see if the fluid returns to the drainage-collection container
Correct Answer: D Irrigate the NG and check to see if the fluid returns to the drainage-collection container
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year-old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator.
Correct Answer: D. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator.
A chemical explosion occurs at a nearby industrial site. The nurse receiving this report should know that this will first require activation of A.A code blue alert B.A disaster medical assistance team C.The local police and fire department D.The hospitals emergency response plan
D is the correct answer
A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right hip and leg numbness d. Multiple fractured ribs and shortness of breath
D is the correct answer
A nurse is field tagging clients after and industrial accident. Which client condition should the nurse triage with with a red tag? A.Dislocated right hip and open fracture of the right lower leg B.Large contusion to the forehead and bloody nose C.Closed fracture of the right clavicle and arm numbness D.Multiple fractured ribs and short of breath
D. Multiple fractured ribs and short of breath
A confused client who fell out of bed because the side rails were not used is an example of which type of liability? A.Felony B.Assault C.Battery D.Negligence
D. Negligence
A nursing instructor asks a student to identify a situation that involves invasion of a patient's privacy. Which example identified by the student indicates an understanding of a violation of this patient's right? A.Performing a procedure without consent B.Threatening to give a patient a medication without his/her permission C.Telling the patient that he or she cannot leave the hospital D.Observing care provided to the patient without the patient's permission
D. Observing care provided to the patient without the patient's permission
