Leadership Practice Q's
The critical care unit of a hospital utilizes team huddles at change of shift. This is an opportunity for the clinical supervisors to connect with team members and review the upcoming shift or any quick topics that need to be communicated. This is an example of a(n) __ meeting. 1. information-sharing 2. opinion-seeking 3. problem-solving 4. strategy
1.
A 50-car pileup occurs on a major freeway in California's Central Valley as a result of heavy fog. There are major injuries, and victims are expected to be transported to local emergency departments. Which type of disaster is this classified as: A. Mass casualty event B. Conventional disaster C. Biological disaster D. Radiological disaster
A.
A nurse who is caring for a group of clients in the medical department has one unlicensed assistive personnel (UAP) assigned to the same group of clients. Which task should the nurse assign to the UAP? A. Accompany a discharged client with chronic kidney disease (CKD) to a private car. B. Pick up clients' lunch trays and take them to the dietary department. C. Obtain a STAT serum glucose level for a client who has a low glucometer reading. D. Change the bed linens for a client who is being transferred to the rehabilitation unit.
A.
All-hazards disaster is best defined as: A. all types of natural and human terrorist events. B. an event involving floods, tornadoes, hurricanes, and earthquakes. C. an unforeseen and often unplanned event causing great damage. D. any type of biological, chemical, radiological, or nuclear event.
A.
A health care system's ability to rapidly expand beyond normal capacity to meet an increased demand for qualified personnel, beds, and medical care services in the event of a large-scale emergency or disaster is known as: A. acuity. B. surge capacity C. mass casualty D. natural disaster
B.
The nursing leadership role once the all-hazards preparedness plan is completed is to: A. confirm that resources are allocated appropriately. B. ensure that every facility department understands their role is a disaster situation. C. establish goals for all-hazards preparedness. D. provide rewards for the committee's accomplishments
B.
192. The nurse has instructed an unlicensed assistive personnel (UAP) in the procedure for collecting a 24-hour urine specimen from a client. The nurse determines that the UAP understands the directions if the UAP makes which statement? 1. "I need to keep the specimen at room temperature." 2. "I need to save the first urine specimen collected at the start time." 3. "I need to discard the last voided specimen at the end of the collection time." 4. "I need to ask the client to void, discard the specimen, and note the start time."
4.
Ques 15. Implementation of the electronic medical record as changed the way documentation is done. What is the primary goal for implementing the electronic medical record? 1. Eliminate spelling and grammatical errors. 2. Enhance the nurse ability to read prescriptions. 3. Streamline documentation eliminating narratives. 4. Share information across disciplines and settings.
4.
Ques 28. The nurse is calling the health care provider to question a medication order for a client. What statement by the nurse is using SBAR? 1. "Ms. Jones, a 93-year-old client with a fractured femur a very lethargic and difficult to arouse at times. Her blood pressure has been 98/60- 203-72. Do you want to continue using the narcotics for pain or would you like to order something else?" 2. "Mary Smith was admitted this morning with pneumonia. She came here for longterm care. Do you want to continue all of the medications that she was on there?" 3. "Mr. Green is going home today. We have completed all of his discharge teaching and have his prescriptions ready to send with him. Do you want to think about adding something for pain?" 4. "John Potter's lab values cam back from a few minutes ago. His blood glucose after lunch was 220. Do you want to implement a sliding scale insulin?"
1.
To implement change in the work environment, which action is most important for the nurse-manager to take? 1. Solicit input from coworkers at the beginning of the process. 2. Present to coworkers the advantages of using a different plan. 3. Examine similar change processes in other institutions. 4. Evaluate the feasibility of implementing the proposed change.
1.
Which statement best describes managed care that is implemented by a specific healthcare delivery agency? 1. Each member of the healthcare team performs specific tasks for client care to ensure implementation of a client's critical pathway. 2. One nurse is responsible for the total nursing process required to meet the client's needs throughout hospitalization. 3. The nurse collaborates with other healthcare disciplines to plan and implement coordinated client care. 4. The healthcare provider provides direction for the nurse to assess, plan, and coordinate the client's care.
1.
The director of nursing of a long term care facility is developing a quality improvement project for the facility's units and establishes that a goal of the project should be consistent documentation of pain for all residents. Which statement is the best indicator of this goal's achievement? 1. All of the nursing staff attend mandatory inservice sessions. 2. After one month, an audit shows a 20% improvement in documentation. 3. Random selection of a nurse's charts shows thorough documentation. 4. The staff agree that documentation has improved by 80%..
2.
Ques 16. One mechanism that ensures autonomy in the nursing profession is the: 1. American Nurses Association (ANA). 2. Department of Health Professionals. 3. Nursing Code of Ethics. 4. Professional Regulatory Board.
1.
Ques 3. The court has found that a registered nurse (RN) harmed a patient by violating his rights. The nurse is ordered to pay the patient a large sum of money. The court has determined that the nurse has committed a: 1. civil act. 2. criminal act. 3. critical wrong. 4. quality breach.
1.
Ques 4. A staff nurse came in to work the 7 PM to 7 AM shift. She had met her friends for "happy hour" earlier in the evening. Her breath smells of alcohol. If this nurse is allowed to provide care for patients, she may be at risk for: 1. maleficence. 2. mélange. 3. nonmaleficence. 4. nonmanager.
1.
Ques 6. A patient who is not fully informed about his or her health status is an example of a violation of which ethical principle? 1. Autonomy 2. Justice 3. Utilitarianism 4. Confidentiality
1.
Ques1. A staff nurse is facing a dilemma between meeting clinical ethical standards and meeting organizational goals. The nurse manager understands that the best way to assist staff members in resolving ethical dilemmas effectively is to focus on: 1. doing the right thing and taking the right action. 2. meeting clinical standards before organizational goals. 3. meeting organizational goals before clinical standards. 4. referring indecisive staff members for additional training.
1.
Effective groups will have a variety of roles. Which of the following are examples of group-building roles? 1. Encourager 2. Listener 3. Summarizer 4. Compromiser 5. Recorder
1., 2., 3.
Ques 30. The nurse is preparing a presentation for a new group of unlicensed assistive personnel (UAP) to discuss documentation. What should the nurse include in the presentation? Select all that apply. 1. Legal aspects of documentation. 2. Importance of documenting opinions. 3. Need for documentation to be legible. 4. Role of the UAP with the electronic medical record. 5. Samples of inappropriate documentation.
1., 3., 4., 5.
Ques 17. The major responsibility for upholding patient care standards belongs to the: 1. chief executive officer of the facility 2. nurse manager. 3. on-call physician. 4. staff nurse providing patient care.
2.
Ques 29. The charge nurse is explaining to the new nurse the role of the licensed vocation/ practical nurse (LVN/LPN) on the acute care unit. What is included in the LVN/LPN's scope of practice? Select all that apply. 1. Developing a plan of care for assigned clients. 2. Administering routine medications to stable clients. 3. Conducting client teaching 4. Collecting subjective and objective data. 5. Analyzing assessment data for decision making.
2., 4.
A small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable and whose membership should be consistent is known as a: 1. Committee 2. Group 3. Team 4. Unit
3.
Ques 11. The nurse is delegating care for a team clients. Which client would be most appropriately delegated to an unlicensed assistive personnel (UAP)? 1. Client with difficulty swallowing. 2. Client with continuous tube feedings. 3. Client requiring a clean catch urine specimen. 4.Client just transferred from ICU..
3.
Ques 12. A new RN is observed breaking sterile technique by the perioperative nurse. This is an example of a violation of which ethical principle? 1. Autonomy 2. Justice 3. Nonmaleficence 4. Confidentiality
3.
Ques 12. The most common source of legal liability for nurse managers is a(n): 1. medical malpractice suit. 2. organizational nursing issue. 3. tort. 4. vicarious liability.
3.
Ques 13. A nurse manager is evaluating the efficiency of a process on the nursing unit. The manager believes that the unit could be more efficient if one aspect of this process were delegated to unlicensed personnel. To establish whether the delegation of this duty would be legal, he should check with the: 1. ANA. 2. current federal defense attorney. 3. state nurse practice act. 4. policy and procedure manual of the unit.
3.
A collection of individuals who are led by a strong, clearly focused leader and who come together to share information and ideas and possibly make decisions is known as a: 1. committee. 2. pseudo team. 3. team. 4. work group.
4.
A multidisciplinary committee meets monthly to discuss medication safety issues within the acute care areas. The quality director consistently arrives late for meetings and spends her time in the meeting answering e-mails on her smart phone. What type of disruptive behavior does this exhibit? 1. Compulsive talker 2. Interrupter 3. Squasher 4. Unreliable
4.
A temporary group of individuals formed to carry out a specific mission or project is known as a: 1. Club 2. Group 3. Meeting 4. Taskforce
4.
Ques 18. Nurse managers are able to respond better to ethical dilemmas when they have access to the organization's: 1. mission and vision. 2. patient safety plan. 3. medical staff bylaws. 4. ethics committee.
4.
Ques 2. On admission, the patient was found to have a blood glucose level of 218. The RN knows that except in emergency situations, it is hospital policy to obtain physician's orders before administering any medication. Because the on-call physician did not return the page, the nurse administered insulin according to the common sliding scale. Four hours later, the patient was found nonresponsive in her bed and later died. According to the autopsy, the patient died from heart failure. Her postmortem blood glucose level was 22. Because of the nurse's actions, the admitting hospital may be found to be: 1. a judicial risk. 2. an ostensible authority. 3. indemnified. 4. vicariously liable.
4.
Ques 8. The nurse on a medical unit is caring for a 19-year-old with complications from a congenital heart defect. The client's mother is consistently at the bedside asking questions and attempting to direct the treatment plan. Which of the following shows how the nurse should communicate with the mother? 1. Discuss personal information that the client shared with the nurse in confidence. 2. Provide the mother with any information required for continuity of care. 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the client if he gives permission for the nurse to share information with the mother.
4.
Ques.15. Which ethical principle is violated when there are insufficient community resources to meet the needs of low-income families? 1. Nonmaleficence 2. Autonomy 3. Beneficence 4. Justice
4.
Team building is the process of __ a group. 1. Forming 2. Identifying 3. Organizing 4. unifying
4.
The labor and delivery nurse calls the healthcare provider to report the onset of late decelerations of the fetal heart rate in a laboring client. The healthcare provider tells the nurse to continue monitoring the client and to call back in one hour. What initial action should the nurse take? 1. Continue to monitor the client per the provider's instructions. 2. Report the provider's response to the chief of the medical staff. 3. Ask the client's husband to call the healthcare provider. 4. Call the nursing supervisor to report the current situation.
4.
The nurse manager within a small department has requested that the staff decide department coverage over the holidays. The department is not associated with patient care and serves as a supportive role to the organization. The staff is to present the manager with the coverage plan during the month of December. This is an example of which type of decision? 1. Autocratic decision procedure 2. Consultative decision procedure 3. Joint decision making 4. Delegated decision procedure
4.
On the second postoperative day, a client is pulseless, apneic, and unresponsive. In what order should the nurse implement these nursing actions? (Arrange from first on top to last on the bottom.) 1. Delegate emergency responsibilities 2. Initiate chest compressions 3. Ventilate the client 4. Call for assistance
4. 2. 3. 1.
Which of the following questions should be considered in the hospital analysis survey of clinical operations readiness in the event of a disaster? (Select all that apply). A. Does the facility have procedures in place to maximize staff safety in a disaster? B. Does the facility have procedures in place for use of PPE? C. Can the facility track patients until discharge or death while maintaining confidentiality? D. Does the facility have a lockdown plan in case of emergency? E. Does the facility have a mechanism of tracking costs associated with the event?
A., B., C.
Hospital leadership should consider which of the following ethical dilemmas prior to experiencing an actual disaster? (Select all that apply.) A. Which clinical leader will make the decision about distribution of scarce resources B. Criteria to determine which patients receive aggressive treatment and which will receive palliative care C. Which nursing staff will be the first to report to the hospital in the event of a disaster D. How prophylactic pharmaceuticals will be distributed to protect staff and their families E. Who will be primarily responsible for external communication
A., B., D.
The hospital plays an important role in the community in the case of a disaster. What are some of the expected roles of the hospital? (Select all that apply.) A. Stockpiling emergency equipment B. Purchasing personal protective equipment (PPE) C. Providing additional security for the community D. Educating staff on all-hazards preparedness E. Providing emergency shelter to community members
A., B., D.
Nursing leadership competencies in disaster planning and crisis management encompass which of the following domains? (Select all that apply.) A. Assessment of the disaster scene B. Technical skills C. Budget and resource allocation D. Risk communication E. Critical thinking
A., B., D., E.
What are the major roles of nursing leadership in disaster planning? (Select all that apply.) A. Providing clearly defined roles for staff nurses in a disaster situation B. Ensuring the synchronization of department plans C. Encouraging staff to stay at home in the event of a disaster to decrease confusion D. Ensuring that the community is synchronizing internal department plans in the event of a disaster E. Developing or refining the hospital's emergency operations plan.
A., B., E.
A disaster is a sudden event that can cause great destruction and human suffering and often requires external assistance. Which of the following statements are accurate depictions of various types of disasters or disaster-related definitions? (Select all that apply.) A. A cyber disaster is a catastrophic event that results from the use of information technology systems. B. A catastrophic event caused by the use of weapons is a radiological disaster. C. A biological disaster occurs when there is a deliberate or unintentional release of biological materials that may affect the health of those exposed. D. A chemical disaster occurs when there is deliberate or unintentional release of biological materials that may adversely affect the health of those exposed. E. A hazard vulnerability analysis is an exercise that identifies an organization's potential emergencies.
A., C., E.
What are the two agencies that require all health care facilities to have detailed all-hazard preparedness plans? (Select two that are correct) A. Patient Protection and Affordable Care Act B. Health Insurance Portability and Accountability Act (HIPAA) C. The Joint Commission D. National Response Plan
B., C.
Testing the all-hazards preparedness plan requires drilling to identify and work through problems. Which of the following are examples of internal drills that can be used to test specific departments and/or hospital responses? (Select all that apply.) A. Surge capacity drills B. Lockdown of hospital entrances C. Prioritization of police response to biological events D. Simulating decontamination processes E. Setting up the command center
B., D., E.
A single-parent mother brings her 3-year-old daughter to the emergency department after the child fell off a playground swing at school and hit her head. Which finding should prompt the nurse to advocate for continued hospital observation of the child instead of discharging the child to care at home? A. The mother states they do not have the money to pay for transportation home. B. The child had a 10 second loss of consciousness immediately after the fall. C. The mother is slurring her words and is not attentive to discharge instructions. D. The child indicates that she is tired and wants to take a nap.
C.
Based on the scope of practice of the practical nurse (PN), which task should the nurse assign to the PN? A. Transport a client to x-ray. B. Restock sterile supplies. C. Assist with a lumbar puncture. D. Distribute afternoon nutrition supplements.
C.
In a disaster, it is most important that the: A. clients are sent home quickly. B. medications and supplies are secure. C. nurses and their families feel safe. D. security department increases its workforce.
C.
The home health nurse is planning care for a client with diabetes. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Notify the healthcare provider of a blood glucose > 400. B. Explain the procedure for inspecting the feet daily. C. Clean the kitchen and bathroom before leaving. D. Assist with bathing and other activities of daily living.
D.
When working with the community, recognizable nomenclature is important for: A. response B. education C. reporting D. communication
D.
185. The nurse notes that an unlicensed assistive personnel (UAP) dons clean gloves but has not washed their hands before taking an oral temperature on a client. The nurse implements a teaching session for UAPs and should incorporate which principle? 1. Learning involves a change of behavior. 2. Learning is a cognitive, passive process. 3. UAPs need constant supervision when caring for clients. 4. Negative rewards reduce undesirable behavior and should be used when an error is seen.
1.
188. The charge nurse is observing a new nursing graduate insert a nasal trumpet airway to provide a route for suctioning the client. The nurse should intervene if the new nursing graduate performs which action? 1. Checks the nose for septal deviation 2. Uses a nasal trumpet that is slightly larger than the nares 3. Inserts the nasal trumpet gently following the contour of the nasopharyngeal passageway 4. Lubricates the nasal trumpet with a water-soluble lubricant jelly containing a local anesthetic
2.
151. A client is being admitted to the neurological unit from the emergency department with a diagnosis of a cervical (C4) spinal cord injury. Which action should the nurse take first when admitting the client to the nursing unit? 1. Listen to breath sounds. 2. Check peripheral pulses. 3. Check for muscle flaccidity. 4. Determine extremity muscle strength.
1.
153. A client is brought to the emergency department by emergency medical services after having seriously lacerated both wrists. The nurse should perform which action first? 1. Assess and treat the wound sites. 2. Contact the crisis intervention team. 3. Collect data on psychosocial aspects. 4. Encourage the client to talk about her or his feelings.
1.
154. The nurse implements a plan of care for a client receiving a chemotherapy treatment with intravenous bleomycin sulfate. The nurse should document which priority intervention in the plan? 1. Monitor for dyspnea. 2. Monitor for alopecia. 3. Monitor for anorexia. 4. Monitor for a change in bowel patterns.
1.
158. A client returns to the nursing unit from the postanesthesia care unit (PACU) after a transurethral resection of the prostate. The nurse should perform which action first? 1. Check the client's respirations. 2. Check the color of the client's urine. 3. Check the urinary (Foley) catheter for patency. 4. Read the nursing notes written by the PACU nurse.
1.
168. The nurse is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client on strict bed rest 2. A client scheduled for discharge to home 3. A client scheduled for a cardiac catheterization 4. A postoperative client who had an emergency appendectomy
1.
169. A hospitalized client with type 1 diabetes mellitus tells the nurse that they feel like they are having a hypoglycemic reaction. The nurse should complete which action first? 1. Obtain a blood glucose reading. 2. Give the client 4 oz (120 mL) of orange juice. 3. Prepare to administer 50% dextrose intravenously. 4. Prepare to administer subcutaneous glucagon hydrochloride.
1.
170. A client is admitted to the emergency department with complaints of severe, radiating chest pain, and a myocardial infarction is suspected. The nurse immediately applies oxygen to the client and plans to take which action next? 1. Obtain a 12-lead electrocardiogram (ECG). 2. Call radiology to prescribe a chest radiograph. 3. Call the laboratory to prescribe stat blood work. 4. Notify the coronary care unit to inform them that the client will need admission.
1.
156. The nurse is creating a plan of care for a postoperative client who is receiving morphine sulfate by continuous intravenous infusion for pain. The nurse should include monitoring of which item as a priority nursing action in the plan of care? 1. Constipation 2. Urine output 3. Temperature 4. Blood pressure
4.
171. The nurse is caring for a client with an injury to the brainstem. The nurse should monitor which parameter as the priority? 1. Urine output 2. Electrolyte results 3. Peripheral vascular status 4. Respiratory rate and rhythm
4.
Ques 9. The nurse is long-term care is making assignments to a team that includes one LPN/LVN and 2 unlicensed assistive personal (UAPs). What task is most appropriate for the LPN/LVN only? 1. monitoring vital signs. 2. Dressing changes. 3. Ambulating clients.. 4. Routine ADLs
2.
Ques18. The charge nurse us reviewing another nurse's documentation for a postoperative client who just returned to the unit following abdominal surgery with a general anesthetic. The nurse caring for the client documented that active bowel sounds were heard in all 4 quadrants. What is the most appropriate action by the charge nurse? 1. Compliment the nurse on documenting a complete post-operative assessment. 2. Question the nurse about hearing bowel sounds when assessing this client. 3. Go into client's room and assess the client with a focus on an abdominal assessment. 4. Do nothing and wait to see what the nurse documents the next time the client is assessed.
2.
The nurse-manager wants to assign an agency nurse to a client who has a new tracheostomy. What action should the nurse-manager implement? 1. Assign the nurse to the client with the tracheostomy and evaluate the care given. 2. Ask the nurse about her competency to care for the client with the tracheostomy. 3. Request the agency to send a nurse who is experienced with tracheostomy care. 4. Transfer the client to another nurse and use the agency nurse for basic hygiene tasks.
2.
Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? 1. Update the nutrition needs in the plan of care. 2. Bathe an unconscious client with decubitus ulcers. 3. Teach insulin self-administration for a client with Type 1 diabetes. 4. Evaluate goal attainment for a client with a below-the-knee prosthesis.
2.
199. The nurse is observing an unlicensed assistive personnel (UAP) talking to a client who is hearing impaired. The nurse should intervene if the UAP performs which action during communication with the client? 1. Speaks in a normal tone 2. Speaks clearly to the client 3. Faces the client when speaking 4. Speaks directly into the impaired ear
4.
183. A hospitalized client tells the evening nurse that they have received pain medication at 10:00 AM and again at 2:00 PM and that the medication provided no relief from the pain. The client says to the nurse, "Whenever that daytime nurse takes care of me and gives me pain medication it never works! I am so glad that you are here so that I can get some relief from this pain." The nurse has observed this same occurrence with other clients who were cared for by this same daytime nurse and suspects that the daytime nurse is self-abusing drugs. The nurse should implement which action? 1. Report the information to the nursing supervisor. 2. Talk with the daytime nurse who gave the medication to the client. 3. Call the impaired nurse organization and report the daytime nurse. 4. Report the information about the daytime nurse to the police department
1.
191. The nurse is reviewing the preprocedure care for a client who is scheduled for a cardiac catheterization with a nursing student. The nurse determines that the student needs further instruction while preparing the client if the nursing student made which statement? 1. "The procedure takes about 5 hours." 2. "The client may experience flushing feelings during the procedure." 3. "The blood vessels and flow of blood will be examined with this procedure." 4. "There is minimal discomfort with catheter insertion because a local anesthetic is used."
1.
74. The nurse is caring for a child with juvenile idiopathic arthritis (JIA). The nurse should identify which problem as the priority? 1. Complaints of acute pain 2. Unsteadiness when ambulating 3. Embarrassment about appearance 4. Inability to perform self-hygienic measures
1.
A hospital received a bomb threat. While the fire department personnel are evacuating the clients, what action should the charge nurse perform? 1. Obtain a current roster of clients assigned to the unit. 2. Ensure that the narcotics are secured and locked up. 3. Move clients' medical records to a safe location. 4. Notify the operator when the unit is evacuated.
1.
Ques 13. The nurse is meeting with the interprofessional team doing discharge planning. Which statement by the nurse uses SBAR to organize the communication? 1. "The client will be living alone and has a history of falling. The client is not confident with cane walking so I would recommend adding a walked." 2. "Mrs. Jones has been the ideal client. She has complied with all treatment and I am sure she will follow the treatment plan." 3. "The client continues to be confused and I have some real concerns about the discharge plans. Maybe we should add home health care." 4. "The health care provider has provided all of the discharge prescription and I have completed the discharge teaching. The client seems to understand."
1.
The charge nurse is assessing clients who are currently in labor. It is most important for the pediatric healthcare provider to be present for which delivery? 1. 40-week primigravida with hypertension who is receiving magnesium sulfate 2 grams/hour. 2. 37-week multipara who is receiving penicillin G 2.5 million units IV for Group B Streptococcus. 3. 41-week multipara who is requesting an epidural instead of a local anesthetic for delivery. 4. 39-week primigravida with a positive urine drug screen who is receiving antiretroviral therapy.
1.
The nurse is caring for a client with rhabdomyolysis after sustaining multiple crushing injuries. Which intervention should the nurse include in the plan of care to prevent acute renal failure? 1. Central venous catheter insertion for hydration. 2. Blood specimen collection for electrolyte analysis. 3. Anti-inflammatory and opioid analgesics for pain. 4. Diuretic IV administration for third-spacing fluids.
1.
The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? 1. Violation of ethical principles. 2. Poor time management skills. 3. Dissatisfaction of co-workers. 4. Reduction of client complaints.
1.
The primary nurse receives the 0700 shift report for 4 clients on a medical unit. When prioritizing care, which action should the nurse implement first? 1. Administer insulin per sliding scale to a client with a capillary glucose of 285. 2. Assess the lung sounds of a client with pneumonia who is ready to go home. 3. Flush the lumen of a client's triple lumen central venous catheter with saline. 4. Review the potassium levels of a client who receives a daily loop diuretic.
1.
166. A client receiving a blood transfusion develops signs of a blood transfusion reaction. The nurse stops the transfusion and maintains the intravenous (IV) line with normal saline. Which action should the nurse take next? 1. Document the occurrence. 2. Check the client's vital signs. 3. Send the blood bag and tubing to the blood bank for examination. 4. Check the client's urine output, and obtain a urine specimen for analysis.
2.
Ques 14. When delegating client care to an unlicensed assistive personnel (UAP) what does the nurse need to communicate? Select all that apply. 1. The nurse action that is to be performed. 2. What the nurse expects to have reported. 3. Significant information regarding the client. 4. Information about other clients in adjoining rooms. 5. The names of the medications prescribed for the client.
1., 2., 3.
160. The nurse is preparing to perform oral suctioning on a client who has coughed, resulting in secretions in the mouth, and is unable to expectorate the secretions adequately. The nurse determines that there is a prescription for the procedure and explains the procedure to the client. Which actions should the nurse take to perform this procedure? Select all that apply. 1. Washes hands 2. Applies a face shield 3. Removes the client's oxygen mask 4. Tells the client not to cough or breathe during the procedure 5. Applies a clean disposable glove to the dominant hand and attaches the suction catheter to the connecting tubing 6. Inserts the catheter into the client's mouth and moves the catheter around the mouth, pharynx, and gum line until secretions are cleared
1., 2., 3., 5., 6.
Ques 4. What is the purpose of the Nurse Practice Act for any given state? Select all that apply. 1. Define nursing for that state. 2. regulate nursing practice within the state. 3. Set standards of care for the state. 4. Differentiate practice by education. 5. Set standards for nurse education programs.
1., 2., 4.
181. The nurse is preparing to administer a medication to a client and notes that the dose prescribed is higher than the recommended dosage. The nurse calls the primary health care provider (PHCP) to clarify the prescription, and the PHCP instructs the nurse to administer the dose as prescribed. Which action should the nurse take? 1. Call the pharmacy. 2. Contact the nursing supervisor. 3. Administer the dose as prescribed. 4. Contact the medical director on call.
2.
190. The nurse is reviewing the pre-procedure care for a client scheduled to have an echocardiogram after a myocardial infarction. The nurse determines that the student nurse understands the pre-procedure instructions if the student nurse made which statement? 1. "The client needs to sign an informed consent." 2. "The procedure is painless and takes 30 to 60 minutes to complete." 3. "The client cannot eat or drink anything for 4 hours before the procedure." 4. "An allergy to iodine or shellfish is a contraindication to having the procedure."
2.
Ques 19. The unlicensed assistive personnel (UAP) reports to the nurse that the client fell when trying to get back into bed. What nursing actions will the nurse complete to follow up? Select all that apply. 1. Complete an assessment of the client. 2. Reprimand the UAP for allowing the client to fall 3. Collaborate the UAP to complete an incident report. 4. Discuss the incident with the UAP as a teaching opportunity. 5. Report the incident to the nurse manager.
1., 3., 4., 5.
Ques 25. The home care nurse is training a new unlicensed home health worker. The exhibit below indicated the prescriptions for the client. What prescription(s) could be delegated for the unlicensed home health worker? Select all that apply. Mary Jones (age 86) Discharge home following hospitalization for congestive heart failure 1. Observe & Monitor edema in lower extremities 2. Continue with previous medications 3. Assist with bathing once per week 4. Cardiac and respiratory assessments weekly 5. Monitor food and fluid intake
1., 3., 5.
Ques17. The nurse is planning an in-service for unlicensed assistive personnel regarding being effective team members. What content should the nurse include? Select all that apply. 1. Respect for colleagues. 2. identifying who agrees with you. 3. Being open to others ideas. 4. Communicating clearly. 5. Avoid disagreeing with colleagues.
1., 3., 5.
180. The nurse is observing a nursing student perform nasotracheal suctioning on an adult client. The nurse should intervene if the nursing student performs which actions? Select all that apply. 1. Sets the wall suction pressure at 140 mm Hg 2. Encourages the client to cough after suctioning 3. Inserts the suction catheter during client inhalation 4. Inserts the catheter beyond the point at which the client elicits the gag reflex 5. Applies intermittent suction on the catheter during removal for up to 10 to 15 seconds
1., 4.
Ques 10. The charge nurse id planning the assignments for the day on an acute care unit. What factors should be considered when making the assignments? Select all that apply. 1. Client acuity levels. 2. Room configuration on the unit. 3. Staff requests. 4. Client needs. 5. Staff preparation.
1., 4., 5.
157. A postoperative client who underwent pelvic surgery suddenly develops dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and should prepare to take which action first? 1. Insert a urinary (Foley) catheter. 2. Administer low-flow oxygen through a nasal cannula. 3. Obtain an intravenous (IV) infusion pump to administer heparin. 4. Increase the rate of the IV fluids infusing to prevent hypotension.
2.
165. A client is hospitalized with chest pain, and myocardial infarction is suspected. The client tells the nurse that the chest pain has returned, and the nurse administers one 0.4-mg nitroglycerin tablet sublingually as prescribed. What should the nurse do next before administering another sublingual nitroglycerin tablet if the pain is not relieved? 1. Place the client in a flat position. 2. Check the client's blood pressure. 3. Encourage the client to deep-breathe. 4. Notify the primary health care provider (PHCP).
2.
193. The nurse is teaching an unlicensed assistive personnel (UAP) how to measure a carotid pulse. The nurse should tell the UAP to measure the pulse on only one side of the client's neck for which primary reason? 1. Because the pulse rate will be easier to count 2. To prevent dizziness and a drop in the heart rate 3. So that the client will not feel a sense of choking 4. Because it will provide a more accurate determination of the quality of the pulse
2.
196. A client comes to the hospital emergency department with complaints of severe right lower abdominal pain characteristic of appendicitis. The client does not have any health insurance. The nurse understands that legally the hospital has which obligation? 1. Refer the client to the nearest public hospital. 2. Provide uncompensated care in emergency situations. 3. Have a health care provider see the client before admission. 4. Respect the family's requests to admit their family member to the hospital.
2.
A client is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the client is taken into a treatment room and asks to stay with the client. What action should the nurse implement? 1. Insist that the spouse wait outside the room while resuscitation is being performed. 2. Allow the spouse to be present and ensure that a member of the team explains the care given and answers questions. 3. Explain to the spouse that there will be no time for explanations during the resuscitation efforts. 4. Advise the spouse that if unsuccessful, the resuscitation scene should not be the last memory of a loved one.
2.
A nurse receives an emphatic complaint from a client in a semi-private room that the night shift nurse did not come into the room the entire night. What action should the nurse implement first? 1. Telephone the night shift nurse as soon as possible to ask about the situation. 2. Review the night shift nurse's documentation with the charge nurse. 3. Discuss the situation with staff to determine if this client has a history of complaining. 4. Verify occurrence with client's roommate while he's ambulating in the hall.
2.
An older female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother's original request, which was executed when she was healthy. What information is best for the nurse to provide? 1. The client's original request based on the signed living will for no heroic measures should be followed. 2. The family should be guided to support the client's current decision about the ventilator. 3. The client's cognitive ability should be evaluated before the use of a ventilator is needed. 4. The family should be directed to discuss alternative treatment options with the healthcare provider.
2.
Ques 1. The nurse is orienting a new graduate nurse to the unit. Reviewing the policies and procedures is included in the orientation. What statement by the nurse reinforces the importance of complying with the organization's policies and procedures? 1. "Always refer to the policies and procedures as a reminder for how to do whatever task you are assigned." 2. "If there is a legal question about a practice issue the policies and procedures serve as the standard of care." 3. "the policies and procedures are a recipe for success to make sure we all do things the same way." 4. "Administration develops the policies and procedures for us so that we are providing cost effective care."
2.
Ques 12. The nurse on the quality improvement committee has asked the staff nurses on the unit to participate in evaluating the new protocol. What statement by the nurse describes the role of the staff nurses. 1. "We will conducing a research project so each nurse will need to read the research proposal 2. "Staff nurses on the unit will be implementing the new protocol and documenting your findings." 3. "Each staff nurse will be responsible for identifying problems that would be barriers to implementation." 4. "Once you have implemented the new protocol you will need to report to the committee."
2.
Ques 16. The nurse manager is orienting a new nurse to the charge nurse role. What needs to be included in the orientation regarding delegation? 1. When delegating to an LPN/LVN the nurse is also delegating accountability. 2. The delegating nurse retains accountability for care delegated to non-RN staff. 3. The LPN/LVN can re-delegate an assignment to unlicensed assistive personnel (UAP). 4. The unlicensed assistive personnel (UAP) has the authority to refuse a delegating.
2.
Ques 23. The charge nurse is following up with a staff nurse following a medication error. Which of the statements by the staff nurse could be the root cause for the error? 1. "I checked the client's wristband and asked him to tell me his birthday before I administered the medications." 2. "When I entered the room the client was on his way to the bathroom so I gave him his medications right away." 3. "I doubled checked the medication dosage and route before I took the medication out of the package." 4. "The client was NPO for a lab test so I held the medication until the test was completed."
2.
Ques 24. A neighbor calls the emergency room nurse who is off- duty and at home to report "My son just fell out of a tree and his eyes are rolled back in his head. Please help me." What is the most appropriate action by the nurse? 1. Immediately go to the neighbor's house to assess the boy. 2. Call 911 before going over to assess the boy. 3. Tell the mother that you are off duty and can't do anything. 4. Tell the mother to call her primary health care provider.
2.
Ques 27. The charge is notified that a new postoperative client will be coming to the unit shortly. The exhibit below identified the beds available. What bed will the nurse hold for the new client? Medical Surgical Unit with only beds available in double rooms 1. Roommate: Client with a white count of 17,000 and elevated temperature 2. Roommate: Elderly client being discharged to a rehab facility later today 3. Roommate: Confused client with urinary tract infection 4. Roommate: Adolescent admitted last night after motor vehicle accident
2.
Ques 3. The nurse is Facebook friends with other members of the nursing team. The nurse notes that one of the unlicensed assistive personnel (UAP) posts a comment of Facebook about a client 'it was great to see my neighbor was discharged from the hospital today." Why should this be a concern that needs to be addressed? 1. potential legal issues. 2. potential HIPAA issue 3. potential ethical issues. 4. potential malpractice issue.
2.
Ques 8. After receiving change of shirt report, in what order would the nurse assess the assigned clients? Prioritize in rank order. 1. Elderly client with pneumonia being discharged to long-term care later today. 2. Client with a white count of 14,000 cells/mm3 and a temperature of 102.8 degrees F. 3. Adolescent client admitted for evaluation following a motor vehicle accident 4. Confused elderly client with a urinary tract infection receiving IV antibiotics. 5. Stable postoperative client who received pain medications about 30 minutes ago.
2. 3. 4. 5. 1.
A nurse is complaining about the way medications are being administered on the nursing unit. What action should this nurse implement? 1. Discuss concerns with other nurses on the unit. 2. Continue with the present unit policy and procedures. 3. Propose an alternative method to administer the medications. 4. Relay the perceived problem to the director of nursing services.
3.
176. The charge nurse is observing a new nursing graduate perform an ear irrigation to remove impacted cerumen from the client's ear. The charge nurse should intervene during the procedure if the new nursing graduate performs which action? 1. Washes hands before performing the procedure 2. Positions the client with the affected side up after the irrigation 3. Warms the irrigating solution to a temperature that is close to body temperature 4. Directs a slow, steady stream of irrigation solution toward the upper wall of the ear canal
2. Positions the client with the affected side up after the irrigation
Ques 26. the nurse case manager is planning care for a client who had a total knee replacement 10 days ago and is being discharged from a rehabilitation center. What other disciplines should the nurse case manager seek input from to develop the plan of care? Select all that apply. 1. Chaplain. 2. Physical therapist. 3. Home health nurse. 4. Respiratory therapist. 5. Pharmacist.
2., 3.
A nurse sitting in the hospital cafeteria sees a man place a small box in the corner and then look around as though he is trying to determine if anyone is looking at him. He then walks quickly to the cafeteria exit. Which action should the nurse implement first? 1. Make a mental note of the appearance of the man. 2. Alert the kitchen staff and have them call 911. 3. Use the nearest phone to notify hospital security. 4. Calmly instruct everyone in the cafeteria to leave.
3.
182. The charge nurse is observing a new nursing graduate insert an indwelling urinary (Foley) catheter. The charge nurse should intervene if the new nursing graduate begins to perform which actions? Select all that apply. 1. Lubricates the catheter before inserting it 2. Positions the client in a side-lying position 3. Inflates the balloon to test patency before inserting the catheter 4. Cleans the area around the urinary meatus before inserting the catheter 5. Inflates the balloon as soon as urine begins to flow through the catheter tubing
2., 3., 5.
177. The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the nurse noted the UAP performing which actions? Select all that apply. 1. Turning the client's head to one side 2. Placing the client in a flat supine position 3. Using small volumes of fluid to rinse the mouth 4. Using a gloved finger to open the client's mouth 5. Placing an emesis basin under the client's mouth
2., 4.
178. The nurse is observing a student donning a pair of sterile gloves and preparing a sterile field. The nurse should intervene if the student performs which actions? Select all that apply. 1. Puts the right glove on and then the left glove 2. Dons the sterile gloves without washing the hands 3. Uses the inner wrapper of the gloves as a sterile field 4. Maintains the gloved hands below the level of the waist 5. Touches the gloves on the overbed table, removes them, and dons another sterile pair
2., 4.
152. The nurse notes redness, warmth, and a purulent drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse should take which priority action? 1. Change the intravenous tubing. 2. Slow the rate of infusion of the TPN. 3. Notify the primary health care provider. 4. Call the pharmacy for a new bag of TPN solution.
3.
159. A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives on the unit, which action should the nurse perform first? 1. Weigh the child. 2. Take the child's temperature. 3. Place the child on a pulse oximeter. 4. Administer the prescribed antibiotic.
3.
161. The nurse hears the alarm sound on the telemetry monitor, quickly looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room, and on reaching the client's bedside, the nurse should perform which action first? 1. Open the airway. 2. Begin chest compressions. 3. Determine unresponsiveness. 4. Deliver 2 effective breaths.
3.
163. The community health nurse is assisting residents involved in a hurricane and flood. Many of the older residents are emotionally despondent and refuse to evacuate their homes. With regard to rescue and relocation of the older residents, the nurse should plan to perform which action first? 1. Contact families. 2. Attend to emotional needs. 3. Attend to nutritional and basic needs. 4. Arrange for transportation to shelters.
3.
167. A client with a diagnosis of sickle cell crisis is being admitted to the hospital. The nurse anticipates that which priority intervention will be prescribed? 1. Laboratory studies 2. Genetic counseling 3. Oxygen administration 4. Electrolyte replacement therapy
3.
197. The nurse tells an unlicensed assistive personnel (UAP) that a client recovering from a myocardial infarction requires a complete bed bath. During the bath, the nurse should intervene if the nurse observed the UAP performing which action? 1. Washing the client's chest 2. Giving the client a back rub 3. Asking the client to wash her or his legs 4. Washing the client's perineal area
3.
200. The nurse administers a fatal dose of morphine sulfate to a client. During the subsequent investigation of error, it is determined that the nurse did not check the client's respiratory rate before administering the medication. Failure to adequately assess the client is addressed under which function of the nurse practice act? 1. Defining the specific educational requirements for licensure in the state 2. Describing the scope of practice of licensed and unlicensed care providers 3. Identifying the process for disciplinary action if standards of care are not met 4. Recommending specific terms of incarceration for nurses who violate the law
3.
A Spanish-speaking client is scheduled for surgery in the morning and preoperative teaching needs to be completed. Since the primary care nurse speaks very little Spanish, which person is best to translate the instructions to the client? 1. A Spanish-speaking UAP who has worked on the unit for many years. 2. The client's husband who is an attorney at a large local law firm. 3. A practical nurse working on another unit who speaks fluent Spanish. 4. The primary care nurse with the help of the Spanish speaking UAP.
3.
A new graduate nurse places a folder on the food cart so intake can easily be recorded, but at the hospital where the nurse is employed, intakes are often estimated because no recordings are made as the trays are picked up. At a staff meeting, the nurse suggests that the recordings be made as trays are picked up. What factor related to entry into practice is the nurse-manager using when the suggestion moves to the implementation of a policy? 1. Nurturing. 2, Mentoring. 3. Biculturalism. 4. Role modeling.
3.
Ques 2. The new graduate nurse is being orientated by a nurse preceptor. The new graduate asks "why do you belong to a professional nursing organization?" What is the most appropriate response by the nurse preceptor? 1. "I was in the student nurse organization then felt like I should become a member of a professional organization when I graduated. 2. "I get additional points at my annual performance evaluation because I can prove I am a member of one of the nursing organizations." 3. "It is a good way to stay involved with the big picture of nursing by advocating for the profession and establishing guidelines for practice." 4."I really enjoy the socialization with other nurses across the county and the dues have been tax deductible as a professional expense."
3.
Ques 20. The nurse case manager for a hospice client reviews the goals of the interprofessional team at the meeting with the family. What is the priority goal? 1. Treatment of disease symptoms 2. Keeping the client at home. 3. Providing comfort care. 4. Providing cost effective care.
3.
Ques 22. The nurse is recommending a change in practice based on evidence-based practice. Which statement by the nurse reflects an understanding of evidence-based practice? 1. "I think we should change the practice because the way I learned to do in school was different. Both my teachers and the book said to do it this way." 2. "For the last couple years, I have done it this way and the outcomes have been good. So I would like to change the practice." 3. "I was at a conference recently and hear about this new technique and I have two recent research publications that support it." 4. "We keep doing the same thing and getting the same outcomes that no one is happy with so let's try something different and see what happens."
3.
Ques 5. The nurse witnesses another nurse bully a colleague. What is the best action for the witness to take? 1. Confront the nurse who is bullying the colleague. 2. Came to the rescue of the victim of the bullying. 3. Report the observation to the charge nurse. 4. ignore it but watch to see if it happens again.
3.
Ques 6. The nurse reports to work for the schedules shift. The nurse manager tells the nurse to report to the emergency department today as a float nurse due to staffing shortages. The nurse has never worked in the emergency department. What is the best action by the nurse? 1. refuse to float to the emergency department. 2. Call the supervisor to report the reassignment. 3. Clarify the reassignment with the nurse manager. 4. Check the policies and procedures regarding float assignments.
3.
The nurse is planning a diabetes education course for a group of clients newly diagnosed with diabetes mellitus. Which collaborative approach is the best use of interdisciplinary team members? 1. Schedule the pharmacist to teach about treatment of hypoglycemia. 2. Assign the occupational therapist to teach insulin injection techniques. 3. Invite the dietician to discuss the timing of meals and snacks. 4. Ask the physical therapist to discuss scheduling physical activity.
3.
The practical nurse (PN) is working with the registered nurse (RN) to provide care for several clients. Which task should the RN, rather than the PN, perform? 1. Apply a neck brace prior to ambulating a client the first day after a cervical laminectomy. 2. Assist a healthcare provider performing a joint fluid aspiration of a client's knee. 3. Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. 4. Remove the staples from a client's incision one week after hip arthroplasty.
3.
What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? 1. Designate 15 minutes a day to respond to each time-waster. 2. Delegate other nursing responsibilities to the team members. 3. Schedule specific times on a written calendar to review 2 charts per day. 4. Review all records 2 days before the due date to focus on the deadline.
3.
Which task should the nurse delegate to the an experienced unlicensed assistive personnel (UAP)? 1. Evaluate the ability of a client to swallow ice one hour after a gastroscopy. 2. Assist a client with initial ambulation after a hip replacement using a walker. 3. Obtain a sterile urine specimen from an indwelling catheter with a closed drainage system. 4. Change the disposable tracheostomy inner cannula when secretions become tenacious.
3.
189. The nurse is observing an unlicensed assistive personnel (UAP) measuring the blood pressure (BP) of a client. The nurse should intervene if which action was observed that would interfere with accurate measurement of the BP? 1. Positions the client's arm at heart level 2. Exposes the extremity fully by removing constricting clothing 3. Explains the procedure to the client and asks the client to rest for 5 minutes 4. Palpates the carotid artery and then places the cuff of the sphygmomanometer 1 inch (2.5 cm) above the brachial artery
4.
195. The nursing student is preparing a client who will have spinal anesthesia for surgery. The nurse in charge asks the nursing student to identify which highest priority preoperative data to report to the nurse on the next shift who will care for the client postoperatively? 1. Pulse rate of 78 beats/min 2. Voided 300 mL preoperatively 3. Blood pressure of 126/78 mm Hg 4. Presence of weakness in the left lower extremity
4.
155. Quinapril hydrochloride is prescribed as an adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should specifically monitor which parameter as the priority? 1. Respirations 2. Urine output 3. Lung sounds 4. Blood pressure
4.
162. The nurse is collecting data on a client with a diagnosis of bulimia nervosa who has problems with nutrition. The nurse should obtain information from the client about which finding first? 1. Lack of control 2. Previous and current coping skills 3. Feelings about self and body weight 4. Eating patterns, food preferences, and concerns about eating
4.
164. An antepartum client at 32 weeks' gestation positioned herself supine on the examination table to await the obstetrician. The nurse enters the examination room, and the client says, "I'm feeling a little lightheaded and sick to my stomach." The nurse recognizes that the client may be experiencing vena cava syndrome (hypotensive syndrome) and should take which immediate action? 1. Give the client an emesis basin. 2. Place a cool cloth on the client's forehead. 3. Call the obstetrician to see the client immediately. 4. Place a folded towel or sheet under the client's right hip.
4.
172. A client is scheduled for a diagnostic procedure requiring the injection of a radiopaque dye. The nurse should check which priority information before the procedure? 1. Intake and output 2. Height and weight 3. Baseline vital signs 4. Allergy to iodine or shellfish
4.
173. The nurse is caring for a client in Buck's extension traction. The nurse should identify which client problem as the priority? 1. Expressed feelings of social isolation 2. Observed inability to distract oneself 3. Verbalized anger about the need for immobility 4. Observed skin redness around the edges of the boot appliance
4.
175. A client has been newly diagnosed with diabetes mellitus. The nurse should perform which action as the first step in teaching the client about the disorder? 1. Decide on the teaching approach. 2. Plan for the evaluation of the session. 3. Gather all available resource materials. 4. Identify the client's knowledge and needs.
4.
179. The nurse reviews the laboratory results of a client receiving chemotherapy and notes that the white blood cell count is extremely low. The nurse asks a nursing student assigned to care for the client to place the client on neutropenic precautions. The nurse determines the need to review the procedures for neutropenic precautions if the student nurse took which action? 1. Removes the water pitcher from the client's room. 2. Removes fresh cut flowers from the client's room. 3. Places a box of face masks at the entrance to the client's room. 4. Leaves fresh pears and apples brought to the client by a family member in the client's room.
4.
184. The nurse determines that a client with a stroke is experiencing difficulty with fine motor coordination when performing activities of daily living. The nurse should suggest that the client be referred to which member of the health care team? 1. Physical therapist 2. Speech pathologist 3. Recreational therapist 4. Occupational therapist
4.
186. The primary health care provider has prescribed a cleansing enema for an adult client. The nurse provides directions to a nursing student who is trained to administer enemas and should tell the student that the maximum volume of fluid that can be administered is which volume? 1. 100 mL 2. 300 mL 3. 500 mL 4. 1000 mL
4.
187. A client requires a partial bed bath. The nurse gives instructions to an unlicensed assistive personnel (UAP) about the partial bed bath and should tell the UAP to perform which action? 1. Just wash the client's hands and face. 2. Provide mouth care and perineal care only. 3. Let the client decide what she or he wants washed. 4. Be sure to bathe the client's body parts that would cause discomfort or odor if left unbathed.
4.
198. The nurse is observing a nursing student auscultating the breath sounds of a client. The nurse should intervene if the nursing student performs which action? 1. Used the diaphragm of the stethoscope 2. Placed the stethoscope directly on the client's skin 3. Asked the client to breathe slowly and deeply through the mouth 4. Asked the client to lie flat on the right side and then on the left side
4.
A nurse who is working the 11 p.m. to 7 a.m. shift enters a client's room when the pulse oximeter alarms and reads 82%. The client appears to be sleeping. Which action should the nurse take first? 1. Gently apply oxygen without waking the client. 2. Record the reading and monitor for further decrease. 3. Reposition the pulse oximeter until it stops alarming. 4. Rouse the client and obtain vital signs.
4.
Four clients arrive on the mental health unit for admission at the same time. Which client should the nurse assess first? 1. An older adult with Alzheimer's disease who is confused. 2. A young adult with phobias that interfere with daily activities. 3. An adult with schizophrenia who stopped taking medications. 4. A middle-aged adult with acute mania who is pacing the hallway.
4.