NCLEX Prioritization

1. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings

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1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

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2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?"

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3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)

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4. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

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5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.

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The nurse has received change-of-shift report. Which client should the nurse plan to assess first? 1. 1-year-old with tetralogy of Fallot who has signs of cyanosis 2. 3-year-old with rheumatic fever who is experiencing sever knee pain 3. 5-year-old with endocarditis who has crackles bilaterally in all lung lobes 4. 7-year-old with measles who has a temperature of 101.2F (38C)

3. Because bilateral crackles in a child with endocarditis indicates a complication, this child should be the nurse's priority

The new nurse is caring for the client with ARF and hypernatremia. Which tasks should the nurse delegate to the NA? Select all that apply. 1. Providing oral care every 3-4 hours 2. Checking skin turgor every 8 hours 3. Changing and IV bag of saline 4. Evaluating daily weights for trends 5. Calculating the intake and output for the past 8 hours

1 & 5 1. Providing oral care is within the NA's scope of practice and does not require advanced knowledge and critical thinking 5. Calculating total intake and output is within the NA's scope of practice; it requires the ability to add, which is usually a job requirement

The nurse is supervising the RN who was reassigned from the orthopedic unit to the ED. Which directions should the supervising nurse provide to the RN who is to care for the client admitted with epistaxis? Select all that apply. 1. "Apply direct lateral pressure to the client's nose for 5 minutes" 2. "Apple ice or cool compresses to the client's nose" 3. "Instruct the client not to blow the nose for several hours" 4. "Be sure to maintain contact precautions" 5. "Position the client lying laterally"

1, 2, & 3 1. The nurse should instruct the nurse in appropriate care, which includes applying direct lateral pressure to the client's nose for 5 minutes 2. The nurse should instruct the nurse in appropriate care, which includes applying ice or cool compresses to constrict vessels and control bleeding 3. The nurse should instruct the nurse in appropriate care, which includes instructing the client not to blow the nose to prevent another episode of epistaxis

The newly oriented patient care assistant (PCA), working under the supervision of the RN, is providing care to clients at a family birthing centre. Which tasks should the nurse delegate to the PCA? Select all that apply. 1. Transporting the client who is 2 days postcesarean section suspected of having a pulmonary embolus to radiology for a chest x-ray 2. Supporting the active labour client, whose spouse has not yet arrived, by having her focus on breathing and relaxation 3. Catheterizing the pregnant client to obtain urine for culture and sensitivity and sending this to the lab 4. Removing meal trays from the client rooms and documenting the amount of intake and percent of meal eaten 5. Obtaining and double-checking a unit of blood with another RN who is preparing the blood for transfusion 6. Recording the 8-hour volume infused IV from IV pumps and clearing the volume infused for all clients

1, 2, & 4 1. The tasks that the PCA could assume include transporting clients 2. The tasks that the PCA could assume would include supporting a woman's breathing techniques 4. The tasks that the PCA could assume include removing meal trays and documenting percent eaten and total intake

The unlicensed NA is providing care to multiple clients under the supervision of the RN. Which activities are appropriate for the RN to delegate to the NA? Select all that apply. 1. Ask the client if the anti-emetic given half hour ago relieved the client's nausea, and report the finding to the RN 2. Observe for and report muscle weakness for the client with a serum potassium level of 3.2 mEq/L 3. Inject air and withdraw medication from a vial after being shown by the RN while the RN administers the client's first prepared medication 4. Cleanse and redress the client's surgical and wound drain dressing on the client's second postoperative day 5. Shave the facial hair with an electric razor for the client who needs to lie flat in bed after spinal surgery

1, 2, & 5 1. The nurse can inform the NA of intended therapeutic effects of an antiemetic and direct the NA to report specific client observations to the nurse for follow-up 2. The nurse can inform the NA of the client's laboratory value alterations and direct the NA to report specific client observations to the nurse for follow-up 5. Hygienic care can be safely performed by the NA and delegated unless the condition of the client would warrant otherwise

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

1. For the client who primarily speaks German, the nurse should first determine the client's literacy level in both German and English so that the nurse can select the appropriate printed materials for client teaching

The nurse manager is evaluating a new nurse's time management skills. Which statements made by the new nurse would demonstrate acceptable time management? Select all that apply 1. "I am late in getting the client ready for radiology because I had to answer some questions from a family member during a client's discharge" 2. "I did not clock out on time because I needed to wait until the end of the shift to document all nursing care provided today" 3. "I did not clock out on time because I admitted the client who came 30 minutes before the end of my shift" 4. "I made morning rounds on all of my clients today before passing medications and starting treatments to be completed during my shift"

1, 3, & 4 1. Due to factors of a constantly changing client care environment, individual components of care may be delayed 3. Due to factors of a constantly changing client care environment, nurses may not finish their assigned shift on time 4. Making rounds on all clients is acceptable as long as treatments and medications are not late due to this practice. There is no indication that treatments and medications were late

The client on a telemetry unit has BP of 88/40 mmHg a HR of 44 bpm, feels faint, and is pale and confused. When caring for this client, which tasks should the RN delegate to the NA? Select all that apply. 1. Paging for the charge nurse 2. Paging for a respiratory therapist 3. Securing an automatic BP machine 4. Placing an oxygen face mask at 2L/min 5. Obtaining a printed cardiac rhythm strip

1, 3, & 5 1. Because the client's condition is deteriorating, additional assistance is needed. The PCA should be able to page for the charge nurse 3. The client should have frequent BP measurements because the BP is low. Securing an automatic BP machine is appropriate delegation 5. Obtaining a printed rhythm strip is appropriate delegation

The RN is working with the UAP and the LPN in providing care to a group of clients. Which tasks should the nurse plan to delegate? Select all that apply. 1. LPN to administer oral and IM medications 2. UAP to perform chest tube dressing changes 3. LPN to assess and care for two non-complex clients 4. UAP to empty and record urinary catheter bag drainage 5. UAP to take and document vital signs on all clients 6. LPN to initiate the discharge paperwork for two clients

1, 4, & 5 1. It is within the LPN's scope of practice to administer oral and IM medications 4. It is acceptable practice for the UAP to empty and record urinary catheter bag drainage 5. It is acceptable practice for the UAP to check and document vital signs on all clients

The experienced LPN is caring for the client with acute substernal chest pain. Which actions should the nurse delegate to the LPN? Select all that apply. 1. Give 325 mg chewable aspirin to the client 2. Give heparin 5000 units IV 3. Administer morphine sulfate 4 mg IV 4. Apply oxygen at 2-4 liters through NP 5. Place leads on the client's chest for cardiac monitoring

1, 4, & 5 1. It is within the LPN's scope of practice to administer oral medication 4. It is within the LPN's scope of practice to administer oxygen 5. It is within the scope of practice of the LPN to attach cardiac monitor leads

The nurse is caring for the client admitted with dehydration. Which actions should the nurse delegate to an experienced LPN who is the only individual working with the nurse? Select all that apply. 1. Take vital signs every 4 hours 2. Evaluate the client's hydration status 3. Consult with the dietitian about the client's swallowing difficulties 4. Provide mouth care every 2 hours while the client is awake 5. Remind the client to avoid commercial mouthwashes

1, 4, & 5 1. Taking vital signs is within the LPN's scope of practice 4. Providing mouth care is within the LPN's scope of practice 5. Reminding the client regarding previously taught instruction is within the LPN's scope of practice

The LPN on the labour and delivery unit reports the RN that the woman's uterus, shortly after birth, is one finger breadth below the umbilicus and is displaced to the right of the abdomen. Which instruction by the RN to the LPN indicates appropriate delegation? 1. "Assist the client to the bathroom so that she can empty her bladder" 2. "Vigorously massage the client's fundus until her fundus feels more firm" 3. "Set an infusion pump in the room while I prepare oxytocin for infusion" 4. "Obtain her vital signs, and I will come and check her fundus in a few minutes"

1. A full bladder causes displacement of the fundus to the right. Having the LPN assist the client to the bathroom will help promote elimination and is appropriate delegation. A full bladder is a concern because the bladder of a postpartum women rapidly fills as the body attempts to rid itself of the extra fluid volume returned from the uteroplacental circulation and from any IV fluids administered. There is also decreased sensation to void and decreased bladder tone caused by the trauma to the urethra and bladder during childbirth

The nurse is planning care for the client in the PACU. The client had lengthy abdominal surgery with the general anesthetic agent isoflurane. Which client problem should the nurse plan to attend to first? 1. Acute pain 2. Anxiety 3. Altered skin integrity 4. Falls asleep after being stimulated

1. After managing the ABC's in the immediate post-op period, the focus is on managing pain. General anesthetic agents such as isoflurane are removed quickly through lung exhalation, and, as the client wakens, the need for post-op analgesia increases

The client being treated for exacerbation of depression states, "caring for all my children is just too hard!". Which intervention should the nurse implement initially when providing crisis intervention? 1. Ask the grandparents to assume temporary responsibility for the children's care 2. Provide one-on-one nursing care to reinforce the nurse's commitment to help 3. Arrange for the client to attend a self-help group that addresses parenting stressors 4. Have the client identify the stressors that immediately preceded this crisis situation

1. Arranging for appropriate alternative child care would be considered the initial intervention. This is changing environmental factors, which is the first level of crisis intervention

The nurse learns from the change-of-shift report that a small for gestational age newborn less than 1 day old has a blood sugar of 39 mg/dL. When beginning care for this infant, which action should the nurse perform first? 1. Assess VS and respiratory status 2. Initiate a feeding for the newborn 3. Recheck the newborn's blood glucose level 4. Prepare to administer IV glucose

1. Assessment is the initial step in the nursing process and should be performed by the nurse before decisions are made about necessary interventions. Normal serum glucose for an infant less than 1 day old is 40 - 60 mg/dL

The nurse assesses the postpartum client 2 hours after delivery of a 10lb infant and finds a blood-soaked pad with large clots. Which action should the nurse take initially? 1. Perform fundal massage 2. Notify the primary HCP 3. Start a dilute oxytocin infusion IV 4. Teaching the client how to apply an anesthetic agent after perineal care

1. Because uterine atony is the most frequent cause of postpartum hemorrhage, initial management is fundal massage

The nurse's morning assessment of the client with HF reveals bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which prescribed intervention should be the nurses priority at this time? 1. Lasix 40 mg IV push q8h x3 doses 2. Enalapril 10 mg PO daily 3. Restrict fluids to 1500 mL per day 4. Echocardiogram as soon as possible

1. Findings suggest fluid volume overload. Diuretics such as Lasix are the first-line treatment for fluid volume overload in the client with HF and should be the priority

The nurse is caring for the client with an STI who is immobile. Which task is most appropriate to delegate to the UAP? 1. Bathing the client including involved areas to provide local comfort 2. Teaching the client to perform frequent hand washing to prevent secondary infection 3. Encouraging the client to use condoms to help prevent the spread of infection 4. Informing the client about the need for sexual partner(s) to receive treatment

1. It is best to delegate bathing because it is within the UAP's scope of practice

The nurse is caring for the client with esophageal cancer. Which task should the nurse delegate to the UAP? 1. Assist the client with oral hygiene 2. Observe the client's response to feeding 3. Facilitate expression of grief or anxiety 4. Apply viscous lidocaine to mouth sores

1. Providing oral care is within the UAP's scope of practice. Providing oral care does not require advanced nursing skills. Orientation to the unit would include oral care needs of clients with cancer who have undergone radiation or chemotherapy

The nurse is admitting a client with OCD who has ritualistic behaviour. Which intervention should the nurse best delegate to ancillary staff? 1. Assisting the client to store personal belonging so as to minimize the client's anxiety 2. Asking the client to identify someone who can be notified regarding the client's admission 3. Providing the client with the general "unit rules" that the client will be expected to follow 4. Encouraging the client to "talk to someone" if feeling anxious, excited, or out of control

1. The client with OCD who has ritualistic behaviour may find storing belongings stressful if not done in a particular manner. Facilitating the client is storing belongings in a fashion that does not produce stress in an intervention that the RN can delegate to the ancillary staff

The new nurse has been on orientation for two months. Which client is best for the charge nurse to assign to the new nurse? 1. 2-year-old with a truncus arteriosus receiving digoxin 90 mcg by mouth 2. 4-year-old who had a balloon dilation procedure as palliative treatment for coarctation of the aorta 3. 6-year-old with endocarditis whose parents need teaching about child care and good hygiene 4. 8-year-old post heart transplant two months ago with a low-grade fever and tachycardia

1. The client with truncus arteriosus receiving digoxin is the most stable client of the options and is best for a new nurse's assignment

The LPN is working under the supervision of the experienced RN. The charge nurse should assign which client to the LPN? 1. 48-year-old with cystitis who has occasional bladder spasms and is taking oral antibiotics 2. 52-year-old with pyelonephritis and sever acute flank pain receiving IV abx 3. 64-year-old with kidney stones receiving IV push narcotics and is to have lithotripsy 4. 72-year-old with urinary incontinence who needs teaching regarding bladder training

1. This 48-year-old client is the most stable client. The LPN should be able to treat the client's bladder spasms with medication and administer the oral antibiotics

The hospitalized client with HF is receiving dobutamine IV. Of the associated responsibilities in the care of the client, which statement is most appropriate for the RN when delegating to the experienced NA? 1. "Teach the client about the reasons for remaining on bedrest". 2. "Take the client's vital signs every hour and report them to me". 3 Turn off the infusion pump if the client becomes hypotensive". 4. "Inform the HCP on the rounds that the client's urine output is low

2. An experienced NA would be able to monitor the client's vital signs and should know to report significant changes to the RN

The client is returning to a unit after ECT. Which intervention should the nurse delegate to an unlicensed ancillary staff member? 1. Assessing the client's LOC every 15 minutes 2. Observing the client for restlessness or agitation and reporting it to the nurse 3. Assisting with the client's first food and beverage intake after the treatment 4. Informing the client's family that the client's memory loss is generally temporary

2. Asking the ancillary staff member to observe the client's behaviour and report any changes is appropriate

The UAP is caring for the client with DKA. Which action can the nurse safely delegate to the UAP? Select all that apply. 1. Check fingerstick glucose results every hour 2. Record intake and output every hour 3. Measure vital signs every 15 minutes 4. Assess lips, tongue, and mucous membranes every hour 5. Analyze the client's cardiac rhythm every hour

2 & 3 2. Recording I&O is within the UAP's scope of practice 3. Measuring vital signs is within the UAP's scope of practice

The NA is assisting in the preoperative preparation of the client. Which tasks should the nurse delegate to the NA? Select all that apply. 1. Inserting the client's NG tube 2. Obtaining the client's vital signs 3. Recording output after emptying a urinary drainage bag 4. Completing the preoperative checklist 5. Witnessing the client's signature on an operative consent form

2 & 3 2. Obtaining vital signs is within the NA's scope of practice. The nurse should consider the knowledge and skills of the person receiving the delegation 3. Emptying a urinary drainage bag and recording output are within the NA's scope of practice

The charge nurse is leading the orientation of new employees. Which statements made by the charge nurse demonstrate appropriate delegation? Select all that apply. 1. "The LPN can delegate dressing changes to the unlicensed assistive personnel (UAP) 2. "The LPN can administer immunizations to a child less than 2 years of age" 3. "The,LPN can add a dose of chemotherapy to an existing IV infusion" 4. "The competent UAP can help transfer stable clients using a mechanical lift" 5. "The UAP can assess the client 15 minutes after a blood transfusion"

2 & 4 2. The LPN can administer most medications; this would be appropriate delegation 4. Once competency is demonstrated, it is appropriate to delegate transfer of the client using a mechanical lift to the UAP

The LPN is working with the RN. Which clients should the RN assign to the LPN? Select all that apply. 1. Client who needs an intravenous patient-controlled analgesia (PCA) device for pain control 2. Client with a leg case who needs CMS checks every four hours and oral pain medications PRN 3. Client who underwent a below-the-knee amputation and is experiencing phantom limb pain 4. Client who was physically abused and now has sever abdominal pain rated at 8 our of 10 5. Client with arthritis who needs routine analgesic medication and heat application to joints

2, 3, & 5 2. Focused assessments such as CMS checks and administering pain medications by mouth are within the LPN's scope of practice 3. The LPN can assist the client with phantom limb pain on measures to control the pain 5. Administering oral pain medications and heat applications are within the LPN's scope of practice

Six new graduate nurses are hired on a busy oncology unit. What should be the nurse manager's role in orientation? Select all that apply. 1. Ensure that each new nurse develops expertise in the client population of the unit 2. Ensure that each new nurse is socialized into the oncological clinical unit 3. Verify that each new nurse completed the licensure process before starting the position 4. Verify that each new nurse participates in the unit's orientation program 5. Verify that each new nurse completes the competency verification process

2, 4, & 5 2. The nurse manager's role is management of the unit, which includes ensuring that new nurses are socialized into the clinical setting 4. The nurse manager's role is management of the unit, which includes verifying that the new nurses are participating in the unit orientation 5. The nurse manager's role is management of the unit, which includes ensuring that the new nurses are completing the competency verification process

The nurse received a change-of-shift report on four assigned clients. In what order should the nurse attend to the clients? Prioritize the nurse's actions by placing each client in the correct order. 1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has a serum potassium level of 5.5 mEq/L 2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of 102.8F, BP 98/66 mmHg, and P 114 bpm 3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who has been crying since recent visitors left 4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a medication for pain rated at a 6 on the 0 - 10 scale.

2, 4, 1, 3 2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of 102.8F, BP 98/66 mmHg, and P 114 bpm should be attended to first. The elevated temperature, low BP, and tachycardia are signs that indicate septic shock or sepsis may be developing. 4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a medication for pain rated at a 6 on a 0-10 scale should be attended to next. Post-op pain control is needed to keep on top of the pain and enable the client to be involved in post-op activities, such as coughing and deep breathing, to prevent complications of bed rest 1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has a serum potassium level of 5.5 mEq/L should be attended to third. The serum potassium level is borderline high (normal 3.5-5.5) 3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who has been crying since recent visitors left can be attended to last among the clients. The client needs emotional support, which is important to recovery, but clients with physiological needs are priority.

The RN and NA are assigned to care for a group of clients. During shift report, the RN learns that a BP taken 1 hour previously for the client was 198/94 mmHg and that the previous shift RN did not intervene. Prioritize the order that the RN should implement the interventions. 1. Notify the client's HCP 2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to retake the BP every 15 minutes 3. Administer the newly prescribed lasix and enalapril 4. Assess the client asking specific questions related to headache, dizziness, and orientation 5. Inform the charge nurse of the client's critically high BP and the actions taken

2, 4, 1, 3, 5 2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to retake the BP every 15 minutes should be first. Current values are needed prior to notifying the HCP 4. Assess the client asking specific questions related to headache, dizziness, and orientation after the NA obtains the BP. A stroke can result from uncontrolled hypertension 1. Notify the client's HCP about the client's elevated BP is next. Essential information is needed before calling 3. Administer the newly prescribed lasix and enalapril. Interventions are needed to quickly lower the client's BP 5. Inform the charge nurse of the client's critically high BP and the actions taken. If the situation is under control and the charge nurse's assistance is not needed, then the charge nurse can be informed of the situation after actions are taken

The NA reports to the RN that the woman is shivering uncontrollably 1 hour after giving birth. Which is the nurse's best response to the NA? 1. "Offer the woman a bedpan; a full bladder can cause shivering" 2. "Bring the woman additional warm bath blankets and a warm drink" 3. "Check her vital signs; shivering may elevate her BP 4. "Thank you; I will give chlorpromazine for her shivering"

2. A heated bath blanket next to the woman and a warm drink help alleviate the shivering this is the best response. Shivering is common in the fourth stage of labour and is thought to be caused by exhaustion, a difference in internal and external body temperatures, or a reaction to the fetal cells that have entered the maternal circulation at the placental site

The RN is managing a mental health unit. Which activity should the RN delegate to the unlicensed ancillary staff member? 1. Implement physical restrains prescribed PRN on the 35-year-old client with a history of aggressive behaviour who is threatening to "tear the place apart!" 2. Accompany a group of clients diagnosed with chronic alcoholism to an off-unit AA meeting 3. Explain to the client diagnosed with OCD why the client is not permitted in another client's room 4. Evaluate the ability of a depressed client to perform self-blood glucose checks using a BGM

2. Accompanying clients to off-site treatments is within the scope of practice for unlicensed ancillary staff and is appropriate delegation. This involves a noninvasive action

The UAP reports a sudden increase in temperature of 102.4F (39C) in the 48-hour postoperative client. Which instruction should the nurse give to the UAP when the nurse observes a cup of steaming coffee at the client's bedside? 1. "Encourage oral fluids to prevent the client from becoming dehydrated" 2. "Recheck the temperature 15 minutes after the client finishes the coffee" 3. "Ask the client to drink only cold water and juices for the next 24 hours" 4. "Document this temperature elevation on the flow sheet in client's chart"

2. Assessment of any previous activity that would alter temperature should be make (i.e. smoking or oral intake) and avoided prior to taking the temperature. Asking the UAP to recheck the temperature in 15 minutes is more appropriate

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 nurses priority? 1. "Please check the client's respiratory rate" 2. "Please check the client's blood sugar" 3. "Please check the client's blood pressure" 4. "Please check the client's level of consciousness"

2. Because TPN solution is high in glucose, discontinuing the infusion quickly may result in hypoglycemia. The nurse should ask the LPN to check the client's blood glucose level

The client recovering from HF needs to have diet teaching reinforced prior to being discharged in the afternoon. Which question by the nurse would best assess the LPN's knowledge and skill about reinforcing the diet teaching? 1. "How many times have you taught HF clients about their diets?" 2. "What information will you reinforce regarding the required diet in HF?" 3. "When was the last time you provided diet education to a HF client?" 4. "When was the last time you were observed reinforcing teaching about the client's diet?"

2. Having the LPN describe the information that will be provided is one method of evaluating the LPN's knowledge and skill. Using an open-ended question elicits conversation and details

The nurse is preparing to supervise the inexperienced LPN inserting a urinary catheter. Which question by the nurse would best assess the LPN's knowledge and skill about inserting a urinary catheter? 1. "How many times have you inserted a urinary catheter?" 2. "How would you perform insertion of a urinary catheter?" 3. "When was the last time you were observed inserting a urinary catheter?" 4. "When was the last time you inserted a urinary catheter?"

2. Having the LPN describe the procedure is one method of evaluating the LPN's knowledge and skill. Using an open-ended question elicits conversation and details

The nurse is working with the UAP on a telemetry unit caring for the client who had an MI three days ago. Which task is appropriate to delegate to the UAP? 1. Administering nitro if chest discomfort occurs during client activities 2. Monitoring vital signs and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

2. Monitoring vital signs and oxygen saturation is within the UAP's scope of practice

The nurse is supervising the experienced NA who is new to the unit. Which question is best to evaluate the NA's knowledge and skill in obtaining the client's fingerstick blood glucose, which is a permissible NA-performed skill within the facility? 1. "How many times did you perform a fingerstick blood glucose measurement on the unit in which you previously worked?" 2. "How would you obtain a blood specimen and perform the procedure for measuring the client's blood glucose?" 3. When was the last time you were observed by a RN performing a blood glucose measurement on the client?" 4. "When was the last time you obtained a blood glucose measurement that was out of the normal ranges, and what did you do about this?"

2. The NA describing the procedure is one method of evaluating the NA's knowledge and skills. Using an open-ended question elicits conversation and details.

The RN is speaking to the UAP on the maternal-newborn unit. The charge nurse determines that the RN needs further education regarding appropriate delegation of client care when overhearing the RN make which statement? 1. "I've observed you feeding a newborn; you hold and feed infants safely and accurately" 2. "Prepare a sitz bath for Mrs. Jones, who has a perineal laceration and is uncomfortable" 3. "When checking the infant's temperature, look at the umbilical cord and tell me its colour" 4. "Mrs. Smith's baby just died. You need to prepare the baby for the family's viewing"

2. The NA is able to assist the client with hygiene and should be aware of safety and comfort concerns with a sitz bath

The experienced UAP is caring for clients on a medical-surgical unit. Which task should the nurse plan to delegate to the UAP? 1. Teaching the client how to administer self-injections 2. Recording intake and output on a group of clients 3. Discontinuing the client's CBI 4. Checking while bathin the client for signs of dehydration

2. The UAP should be able to record I&O on a group of clients; recording does not require clinical judgement

The nurse has medications to administer at 1000 to four pediatric clients. Which child should be the nurse's priority for administering medications? 1. A child with a frequent, productive cough who has an antiussive medication due 2. A child with burns who has a debridement at 1045 and needs an oral analgesic 3. A child with aspiration pneumonia who has a scheduled IV antibiotic that is due 4. A child with an infection who has a fever of 102F (38.9C) and is receiving Tylenol

2. The nurse should administer the analgesic first. Because this child will be undergoing a debridement in 45 minutes and the medication is oral, it will take 30-45 minutes for the effects of the medication to occur

The client with HF has sever dyspnea and is anxious, tachypneic, and tachycardic. Which intervention should be the nurses priority? 1. Administer diazepam 2.5 mg IV 2. Administer morphine sulfate 2 mg IV 3. Increase dopamine IV infusion by 2 mcg/kg/min 4. Increase nitro IV infusion by 5 mcg/kg/min

2. The nurse's priority should be giving morphine sulfate. This medication improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea

The primigravida client in the active stage of labour with her first pregnancy states, "I just sneezed and I think I urinated all over myself; I feel wet". Which action is the nurse's priority? 1. Offer the client a bedpan 2. Inspect the client's perineal area 3. Change the client's gown and bed linens 4. Tell the client to being using her breathing techniques

2. The nurse's priority should be to assess the perineum to determine if rupture of the membranes has occurred. A nitrazine strip test can be done to check fluid leaking from the vaginal introitus, but contamination of the strip with urine could result in false-positive test results

The RN caring for the elderly client with dementia as a result of metastatic brain cancer is delegating actions to the NA. Which action is inappropriately delegated to the NA? 1. Toileting the client prior to settling the client in a bed for the night 2. Informing the family that the client will need a follow-up brain scan 3. Accompanying the client on a walk in the gardens on the hospital grounds 4. Reinforcing the client's orientation by frequently stating the year, month, and day

2. The scope of practice for ancillary staff does not include the management of client care. Discussion the client's diagnostic needs is not a responsibility that the RN can delegate to the ancillary staff

The RN is leading a team of an NA and an LPN in the care of a group of clients. Which tasks should the nurse assign to the NA and LPN? 1. NA to perform two simple dressing changes; LPN to assess and care for two non-complex clients 2. NA to empty and record urinary catheter bag drainage; LPN to administer oral and IM medications 3. NA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased client's family 4. NA to take and document vital signs on all clients; LPN to complete the discharge paperwork to be reviewed with two clients

2. The scope of practice for the NA includes measuring and recording I&O and for the LPN includes administering oral and IM medications

The nurse received change-of shift-report on four clients. Which client should the nurse assess first? 1. The 29-year-old client with HF who is experiencing anxiety related to scheduling of a valvuloplasty later today 2. The 40-year-old client with restrictive cardiomyopathy who developed sever dyspnea just before the shift change 3. The 48-year-old client who had a coronary angioplasty 1 day ago and has had occasional pain at the right groin puncture site since the procedure 4. The 58-year-old client who transferred from the intensive care unit 1 day ago after coronary artery bypass graft surgery and has a temperature of 100.6F

2. This client is priority because new onset dyspnea could indicate worsening of the client's condition

The nurse determines that the NA did not complete assigned tasks. Which statement is best? 1. "All four of the clients' rooms assigned to you today are messy with a lot of trash in them. You really need to finish your assignment before you leave". 2. "I am concerned that you didn't complete your work assignments today. What responsibilities interfered with completing the tasks I assigned?" 3. "I checked with the four clients you were assigned to ambulate, and you didn't ambulate anyone. This cannot happen again". 4. "Family members are upset today because you didn't get all the clients bathed yet. Why didn't you let me know you needed help?"

2. This statement is best. Giving the NA an opportunity to provide a rationale fosters team communication.

The nurse delegated to the NA to calculate the 8-month-old's output for the past 8 hours. The child had three wet diapers during the 8-hour shift weighing 45 g, 40 g, and 30 g. The weight of a dry diaper is 15 g. The child also had a 100 mL emesis and 50 mL diarrheal stool. What amount in mL should the NA report for the infant's total output for the 8 hours?

240 1 milliliter of urine output = 1 g of body weight. First add the total weight of each diaper: 45 + 40 + 50 = 135. Next determine the dry diaper weight for 3 diapers 15 x 3 = 45. Subtract the dry weight from the total weight to determine total urine output for 8 hours 135-45 = 90. Next, add the urine output and the output from the emesis and diarrhea 90 + 100 + 50 = 240 mL

The nurse initiated an IVPB of cefuroxime sodium for the client. Within 5 minutes, the client is experiencing dyspnea, wheezing, and stridor. Prioritize the nurse's actions in the order that they should be accomplished. 1. Shout for help 2. Call the HCP 3. Turn off the antibiotic 4. Ask another nurse to set up a new IV maintenance solution and tubing to aspirate the IV port before initiating the new solution 5. Administer the prescribed emergency medications IV 6. Maintain the airway and administer oxygen

3, 1, 6, 4, 2, 5 3. Turn off the antibiotic immediately because it is the cause of the problem 1. Shout for help; extra people will be needed for interventions to stabilize the client 6. Maintain the airway and administer oxygen to treat the client's dyspnea, wheezing, and stridor 4. Ask another nurse to set up new IV maintenance solution and tubing and aspirate the IV port before initiating the new solution. Aspirating the IV port will remove any remaining antibiotic in the port. It is necessary to keep the IV open for the administration of emergency medications 2. Call the HCP to report the client's reaction and status and receive orders. In some settings, the call for help may be to an emergency response team, and an HCP often responds as part of this team. T he client's primary HCP should also be notified 5. Administer the prescribed emergency medication IV

The RN is working with the LPN in providing care to the client. Place the nurse responsibilities associated with delegation, supervision, and evaluation in the order that these should be completed by the nurse. 1. Following and incident, discuss importance of verifying the gag reflex prior to allowing the client who was sedated to have anything by mouth 2. Intervene when the LPN allows the client who had been sedated for a procedure to have food/drink by mouth prior to verifying gag reflex 3. Inform the LPN of tasks pertaining to the clients that should be completed 4. Write a brief anecdotal note regarding appraisal of encounter with the LPN

3, 2, 1, 4 3. Inform the LPN of tasks pertaining to the clients that should be completed should be the first action after giving or receiving report on the clients. The RN is delegating tasks to the LPN 2. Intervene when the LPN allows the client who had seen sedated for a procedure to have food/drink by mouth prior to verifying gag reflex is the second action. This involves supervision 1. Following an incident, discuss the importance of verifying the gag reflex prior to allowing the client who was sedated to have anything by mouth is third. Supervision includes providing feedback 4. Write a brief anecdotal note regarding appraisal of the encounter with the LPN is next. Appraisal involves evaluation

The nurse completes an initial assessment of an adolescent weighing 88 pounds who was injured in a MVA. What should the priority order for the nurse's follow-up of the assessment findings? Place items in the order of priority. 1. The client states "I was given pain medication in the ambulance" 2. Blood is noted at an abdominal wound site 3. Client is responsive, but based on previous documentation is less responsive 4. UO is less than 30 mL in the last 2 hours

3, 2, 4, 1 3. Client is responsive, but based on previous documentation is less responsive; this finding should be followed up first because a change in LOC can be due to hypoxia, hypoglycemia, hypovolemia, abnormal lab values, and other conditions 2. Blood noted at an abdominal wound site is the second priority. The amount nedds to be determined because it could potentially put the child at risk for hypovolemia 4. Urinary output is less then 30 mL in the last 2 hours should be followed up next. Urine output should be 0.5 - 1 mL/kg/hr or 20 - 40 mL/hr (88lb/2.2kg/lb = 40kg). Low urine output could result from inadequate fluids or blood loss 1. The client states, "I was given pain medication in the ambulance". The nurse should follow up to determine when the pain medication was last given, but if the client is comfortable, this can be followed up after addressing the other findings that are more critical

The nurse has been assigned four clients. In what order should the nurse plan to assess the clients? 1. 14-year-old with a UTI who reports urinary burning at a 2 on a 0-10 scale 2. 6-year-old 1 day post-op appendectomy with a temperature of 102.2F (39C) 3. 5-year-old newly admitted with pharyngitis and drooling 4. 2-year-old admitted with diarrhea who had three loose stools on the previous shift

3, 2, 4, 1 3. The 5-year-old who is newly admitted with pharyngitis and drooling should be the first to be assessed. These symptoms of epiglottitis and a medical emergency 2. The 6-year-old 1 day post-op appendectomy with a temperature of 102.2F (39C) should be the second client to be assessed. An elevated temperature suggests an infection. Additional information should be obtained to R/O developing sepsis 4. The 2-year-old admitted with diarrhea who had three loose stools on the previous shift should be the third to be assessed. Additional information should be obtained to rule out fluid and electrolyte imbalances 1. The 14-year-old with a UTI who reports urinary burning at a 2 on a 0-10 scale should be assessed last. Additional information needs to be obtained to determine if treatment is effective. The pain rating of a 2 may be at an acceptable level for the client

The nurse and the experienced LPN are working together to care for the client who is unconscious. Which tasks should the nurse plan to delegate to the LPN? Select all that apply. 1. Listen to the client's lung sounds every 4 hours 2. Check pupil size and reactivity every 2 hours 3. Check an axillary temperature every 4 hours 4. Check enteral feeding residual volumes every 4 hours 5. Turn and massage the client's back every 2 hours

3, 4, & 5 3. The experienced LPN is able to check axillary temperatures every 4 hours and should know to report significant changes to the RN 4. The experienced LPN should be able to check enteral feeding residual volumes every 4 hours and should know to report significant findings to the RN 5. Turning and rubbing the client is necessary to prevent skin breakdown and is appropriate to delegate to the LPN

The nurse receives a change-of-shift report for four assigned clients. Which clients should the nurse attend to first? Place each client in the order of priority. 1. The 44-year-old client who has questions about how to empty the Jackson-Pratt drain at home after being discharged tomorrow 2. The 33-year-old client who has a new order to insert a nasogastric (NG) tube and connect to low intermittent suction 3. The usually oriented 76-year-old client diagnosed with thrombophlebitis who has new onset confusion 4. The 58-year-old client requesting a pain medication for abdominal incision pain rated at a 6 on a 0 to 10 scale

3, 4, 2, 1 3. The usually oriented 76-year-old client diagnosed with thrombophlebitis who has new onset confusion may be a sign of a complication, such as a stroke or pulmonary embolism 4. The 58-year-old client requesting a pain medication for abdominal incision pain rated at a 6 on a 0-10 scale should be attended to next because pain can interfere with necessary post-op activities, such as a deep breathing, coughing, and ambulating 2. The 33-year-old client who has a new order to insert an NG tube and connect to low intermittent suction should be attended to third. There is no indication that this client is nauseated or that the placement of the NG is priority 1. The 44-year-old client who has questions about how to empty the Jackson-Pratt drain at home after being discharged tomorrow should be the last client to be seen. Teaching is a lower priority than interventions for physiological integrity

The adult client is newly admitted to the PACU from surgery. Which assessment finding should be the nurse's priority? 1. The surgical site dressing has a scant amount of blood 2. The client is sleeping but easily arouses when touched 3. The client's respiration's are 6-8 BPM 4. The client's blood pressure 5 minutes ago was 110/68 mmHg

3. A low respiratory rate is the priority because anesthetic agents decrease respiration's. Adult respiration's should be 12-20 BPM

The RN is the preceptor for the new graduate nurse during the new nurse's second week of orientation. Which clients should the charge nurse assign to the graduate nurse under the supervision of the preceptor? Select all that apply. 1. The 16-year-old client with moderate chronic asthma to be discharged in 24 hours 2. The 5-year-old client with a tracheostomy needing tracheostomy care every shift 3. The 12-year-old client who had surgery for a ruptured appendix with a temperature of 99F ( 37.2C) 4. The 8-year-old client just admitted with a new diagnosis of leukemia 5. The 4-year-old client diagnosed with hemophilia and admitted for a blood transfusion

3. An elevated temperature would be expected following a ruptured appendix. This client would have routine care needs and can be assigned to the new graduate nurse

The RN is working with the LPN who is caring for the 12-year-old who has sever abdominal, hip, and knee pain cause by a sickle cell crisis. Which action taken by the LPN is most concerning and requires that the nurse intervene STAT? 1. Checks the client's temperature every hour 2. Places a contact isolation care outside the client's room 3. Places cold packs on both of the client's knees 4. Asks a nursing assistant to obtain the client's vital signs

3. Applying cold packs to the client's knees is most concerning and requires immediate intervention and removal of the packs. Pain in sickle cell crisis is caused from obstruction of blood flow by sickled RBCs. Cold packs would further decrease blood flow to the client's knees and increase sickling

The nurse is delegating the task of bottle feeding the 6-hour-old term newborn to the NA. Before delegating, the nurse should evaluate the NA's knowledge of this task by asking the NA which question? 1. "How many times have you fed an infant previously" 2. "How long have you worked in the newborn nursery?" 3. "How will you position the infant for the feeding?" 4. "Do you have any children who you bottle fed?"

3. Asking open-ended questions about the specific task to be delegated will help the nurse to determine if the NA has the knowledge to perform the assigned task

The nurse assesses that the labouring client receiving an oxytocin infusion has a contraction occurring 1 minute after the previous contraction and has a duration of 95 seconds. Which should be the nurses first action? 1. Notify the HCP 2. Reassess the fetal heart tones 3. Stop the oxytocin infusion 4. Prepare to administer terbutaline sulfate

3. Because oxytocin stimulates contractions, the nurse should first stop the infusion. A contraction that occurs more frequently than every 2 minutes and has a prolonged duration suggests hyperstimulation and approach tetany. This could lead to uterine rupture.

The nurse assesses that the client is pale, diaphoretic, dyspneic, and experiencing chest pain. Which nurse actions are most appropriate 1. Stay with the client, call the charge nurse for help, and call the NA to bring an automatic VS machine to the room immediately. 2. Call the NA to take the client's vital signs while the nurse leaves to obtain a narcotic analgesic for administration and to notify the charge nurse 3. Apply oxygen, call the NA to bring an automatic VS machine, call the charge nurse for help, and ask for medications noted on the MAR 4. Activate the emergency system for a code to get immediate help, apply oxygen, and send responders for needed equipment and medications

3. Because the client is in distress, the nurse should stay with the client, apply oxygen, and obtain help from other members of the health care team

After working with the client, the UAP tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." Which should be the nurse's response? 1. "He has a lot of problems. You need to have patience when caring for him". 2. "It is your responsibility to accept your assignment. I will write you up if you don't". 3. "He may be scared and taking it out on you. Let's figure out what to do together". 4. "Ignore him and get the rest of your work done. I can go in and check on him".

3. Offering to "figure out what to do together" uses problem-solving, fosters team communication, and facilitates teamwork

The client just returned to the nursing unit following a total laryngectomy. Which observation by the nurse requires the most immediate intervention? 1. The client is unable to speak 2. The client is coughing blood-tinged sputum 3. Oxygen saturation is 82% 4. Jackson-Pratt wound drain is half full

3. Oxygen saturation should be above 92% immediate intervention is needed to increase the client's oxygen saturation level, which may include increasing the oxygen concentration, elevating the client's head of the bed, and/or suctioning the client's tracheostomy

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

3. Seeing the client provides an opportunity for further assessment and client teaching. The nurse's responsibility is to inform clients of the status of their care.

The nurse from the oncology unit was reassigned to a burn unit due to a staffing need. Which client should the charge nurse plan to assign to the nurse from the oncology unit? 1. 23-year-old newly admitted with burns on 30% of the body from a house fire 2. 27-year-old recent skin graft recipient needing nutrition and wound care teaching 3. 29-year-old with partial-thickness back and chest burns needing a sterile dressing change 4. 30-year-old with full-thickness burns on both arms needing help with positioning

3. The 29-year-old client is the most stable. The nurse from the oncology unit should be able to complete a sterile dressing change

The nurse manager is reviewing assignments for an evening shift. The nurse manager should intervene if the experienced LPN is assigned which action? 1. Complete a foot soak for the client who has an infected heel ulcer and is on contact precautions for VRE 2. Assist the client who had a vaginal hysterectomy 6 hours ago to sit at the edge of the bed for a few minutes and then ambulate 3. Discharge a 34-year-old who had a right mastectomy 4 days ago and needs instruction regarding incision care and a wound drain 4. Perform intermittent urinary catheterizations for residual urine for the client who had an abdominal hysterectomy 2 days ago

3. The 34-year-old client preparing for discharge will need teaching related to the care of the incision and wound drain and will have other psychosocial and physical needs. The nurse manager should intervene because the RN should assess the client's readiness for discharge and complete the teaching

At 0730 an oncoming shift nurse is planning care for four patients. Which client should the nurse plan to assess first? 1. The 23-year-old client with CF who has pulmonary function tests scheduled in 30 minutes 2. The 35-year-old client admitted the previous day with bacterial pneumonia and now has a temperature of 101.2F 3. The 46-year-old client who had a chest tube removed an hour ago and now has dyspnea 4. The 77-year-old client with tuberculosis who had four anti-tubercular medications due at 0800

3. The client with dyspnea who had a chest tube removed one hour ago is the priority because dyspnea could indicate a pneumothorax

The RN is working with the experienced LPN. Which client should the RN assign to the LPN? 1. 1-year-old who is scheduled to receive chemotherapy 2. 2-year-old who has orders for a platelet transfusion 3. 3-year-old who has loose stools and is incontinent 4. 4-year-old admitted with lethargy and has a temperature of 101F (38C)

3. The nurse should delegate the care of the client with loose stools because the client is most stable of the options, and skin and toilet care is within the LPN's scope of practice

The new nurse is discussing the organization of client care with the mentor. Which statement made by the new nurse requires immediate follow-up by the mentor? 1. "I delegated all the stable vital signs to an unlicensed assistive personnel (UAP) and most of the treatments to the LPN 2. "I had the LPN bring the urinary catheterization supplies into the room so everything would be available when I got there" 3. "I was taking vitals on one client and having a second client dangle while I had a third client sit on the bedside commode" 4. "I believe my organizational skills are improving and I am able to complete all the client cares myself"

3. This statement may appear that the new nurse is organized. However, leaving the client dangling and another on a bedside commode while taking vital signs on another client is unsafe and indicates that the new nurse is not properly delegating tasks. This statement would require immediate follow-up by the mentor because these actions increase the client's risk for falls.

A triage nurse working in an ED received four admissions. Prioritize the order in which the nurse should assess the clients. 1. The 40-year-old client who is diaphoretic and is feeling chest pressure 2. The 18-year-old client who thinks he might have a broken ankle 3. The 35-year-old client who cut her hand with a knife while preparing food 4. The 60-year-old client who is dyspneic and has swollen lips after being stung by a bee

4, 1, 3, 2 4. The 60-year-old client who is dyspneic and has swollen lips after being stung by a bee should be assessed first; the client is likely experiencing an anaphylactic reaction. Airway maintenance and medication administration are required to prevent death 1. The 40-year-old client who is diaphoretic and is feeling chest pressure should be assessed next. The client could be experiencing an MI, and "time is muscle". Ideally, the nurse should be able to delegate actions for this client while assessing the first client 3. The 35-year-old client who cut her hand with a knife while preparing food is a priority because of the potential blood loss. However, this client should be assessed third because it is not as life threatening as either the client with a possible anaphylactic reaction or the client with a possible MI 2. The 18-year-old client who thinks he might have broken ankle is the last client to be assessed. An x-ray is indeed to confirm a fracture, but the client is stable and does not have a life threatening problem

The nurse is planning care for four clients on a pediatric unit. Prioritize the order in which the nurse should plan to attend to the clients. 1. The 13-year-old client waiting to be admitted from the ED after receiving stitches for facial lacerations from a dog bite 2. The 9-year-old client whose mother is present to receive teaching about wound care for her child's left leg skin graft in anticipation of discharge tomorrow 3. The 5-year-old client with an infected leg wound who is scheduled for a dressing change now 4. The 2-year-old client whose temperature has risen to 103.8F (39.9C)

4, 3, 1, 2 4. The 2-year-old client whose temperature has risen to 103.8F (39.9C). This child should be assessed first because this situation is the most life threatening 3. The 5-year-old client with an infected leg wound who is scheduled for a dressing change now should be next. Delaying the dressing change increases the risk of sepsis 1. The 13-year-old client waiting to be admitted from the ED after receiving stitches for facial lacerations from a dog bite is next. The child should still be monitored while in the ED, and it is appropriate to delay admission to the unit if other interventions are priority 2. The 9-year-old client whose mother is present to receive teaching about wound care for her child's left leg skin graft in anticipation of discharge tomorrow is last. This client is being discharged tomorrow, which means that the wound care teaching, while important, can be delayed

The nurse receives shift report on four assigned clients. Prioritize the order that the nurse should assess the assigned clients. 1. the 47-year-old client two days postoperative who has pain rated at a 2 on a 0 to 10 pain scale 2. The 82-year-old client who was unable to void and has a bladder scan showing 300 mL of uring 3. The 76-year-old client newly admitted with serum blood urea nitrogen (BUN) of 52 mg/dL 4. The 57-year-old client with hypertension who has sever mid-sternal pain

4, 3, 2, 1 1. The 57-year-old client with hypertension who has sever midsternal pain should be assessed first. The client may be experiencing angina and needs immediate intervention 3. The 76-year-old client newly admitted with serum BUN of 52 mg/dL should be assessed second. The elevated BUN could indicate dehydration 2. The 82-year-old client who was unable to void and has a bladder scan showing 300 mL of urine should be the third client assessed; if the client is unable to void, the nurse should assess the client, initiate other measures to promote voiding and, if unsuccessful, contact the HCP; the client may need intermittent urinary catheterization for the bladder emptying 1. The 47-year-old client two days post-op who has pain rater at 2 on a 0-10 scale should be assessed last of the four clients. A pain level of 2 may be acceptable to the client

The nurse is assessing the appropriateness of a self-help group for the 20-year-old client recently diagnosed with an eating disorder. The nurse should initially obtain which information? 1. The average age of the self-help group's membership 2. The ratio of clients to involved HCPs 3. How compatible the group's meeting schedule is with the client's expectations 4. The composition of the self-help group' membership and similarity with the client

4. A group that has clients who are similar is more likely to promote positive adaptive responses among its clients

The LPN is assisting with the care of the client with neutropenia. Which nursing action included in the care plan is appropriate for the RN to delegate to the LPN? 1. Teaching the client the purpose of neutropenic precautions 2. Assessing the client for signs and symptoms of infection 3. Developing a discharge teaching plan for the client and family 4. Giving a prescribed subcue injection of filgrastim

4. Administration of medications is included in the LPN education and scope of practice

The nurse observes the LPN providing care for the client who had contact precautions due to a c.diff. infection. Which action by the LPN requires the nurse's immediate correction? 1. Donning medical examination gloves upon entering the client's room 2. Wearing a gown while giving the client a bed bath and changing the bed linen 3. Informing a visitor to wash hands with soap and water upon leaving the client's room 4. Using an alcohol-based hand cleanser for hand hygiene when exiting the client's room

4. Alcohol-based hand cleansers should not be used for hand hygiene with c.diff. The organism forms spores, and alcohol-based antiseptic agents have poor activity against spores

The UAP's job responsibilities include checking vital signs every four hours, completing morning care on assigned clients, assisting clients with activity, answering lights, and totaling I&O records for clients at the end of an 8-hour shift. Near the end of the shift, the LPN reports to the RN that the UAP has not competed all of the morning care on assigned clients. Which is the RN's best action? 1. Remind the UAP that the morning care needs to be completed as quickly as possible 2. Notify the charge nurse that the UAP needs additional orientation on job responsibilities 3. Complete and incident report on the UAP about the inability to complete assigned tasks 4. Ask the UAP about morning care completed and the reasons for uncompleted care

4. Asking the UAP about care completed and the reason for uncompleted AM care will help determine the UAP's understanding of job responsibilities and any impeding factors and is the most appropriate action to be taken by the nurse. The UAP's workload may have been too heavy

While caring for the postoperative client following a total laryngectomy with radical neck dissection, the nurse observes that the client is restless and has a respiratory rate of 28 BPM. Which action is the nurse's priority? 1. Suction the client's laryngectomy tube 2. Apply oxygen by mask at 4 liters per minute 3. Elevate the head of the client's bed to 45 degrees 4. Assess the client's oxygen saturation level

4. Assessment is priority to determine the cause of the client's symptoms

The nurse checks for laboratory results in the electronic medical record of four clients. Based on the results, which client should the nurse assess first? 1. Client who had urine that is positive for ketones 2. Client who has a serum T4 of 10 mg/dL 3. Client who has a 2-hour postprandial glucose of 150 mg/dL 4. Client who had a fasting blood glucose of 40 mg/dL

4. Because a fasting blood glucose of 40 mg/dL is life threatening, the nurse should assess this client first

The NA's job responsibilities include totaling the I&O records for clients at the end of an 8-hour shift. Near the end of the shift, the LPN reports to the RN that the new NA on the unit has not completed the task. What is the RN's best action? 1. Ask the LPN to complete this task because the information is needed to give report. 2. Remind the NA that the task needs to be completed as quickly as possible 3. Notify the charge nurse that the NA needs more orientation on job responsibilities 4. Go to the NA to discuss the collection of I&O data and how to total I&O records

4. Delegation of assigned tasks includes determining the delegate's knowledge and ability to perform the task correctly. Discussing the task with the NA may clarify what the NA knows and where additional teaching is needed regarding the task.

The nurse notes that the client has dyspnea and red blotches on the face and arms and appears anxious following exposure to latex. The nurse calls the ART, who initates emergency treatment. Of all the emergency treatments available, which action should be taken first by ART? 1. Start oxygen at 1 liter per minute via nasal cannula 2. State IV access with a large-bore catheter 3. Administer diphenhydramine 25 mg IM 4. Administer epinephrine hydrochloride 0.4 mL subcue

4. Epinephrine hydrochloride (Adrenalin) is a sympathomimetic that acts rapidly to prevent or reverse cardiovascular collapse, airway narrowing from bronchospasm, and inflammation. It is rapidly absorbed when administered subcue

The NA is caring for the 10-year-old child who has just completed chemotherapy. Which action by the NA requires the RN to intervene? 1. Applies unscented body lotion to the child's dry skin and performed a back and foot massage. 2. Assists the child to put on a freshly laundered hand-sewn hat that a parent brought from home 3. Offers a soft toothbrush with toothpaste for oral care and helps the child rinse with water 4. Applies nystatin oral suspension that was left at the bedside to mouth sores

4. Even though nystatin is an oral suspension applied to the mouth after oral care, medication administration is not within the scope of practice of the NA. The medication should not be left at the client's bedside even if oral care has not yet been performed

The nurse is assigning tasks to the UAP. Which tasks best demonstrate proper delegation? 1. Bathe 10 clients while working the day shift 2. Insert a nasogastric tube to administer a feed 3. Answer the client's question about medication 4. Ambulate the client who had a thoracotomy 3 days ago

4. Generally, by the third day following a thoracotomy, the client may be safely ambulated with the assistance of the UAP

The RN's assessment findings of the 2-year-old with meningitis include an altered LOC, decressed UO, and temperature of 103.4F (39.7C). The LPN who works on an adult oncology unit arrives to assist in "any way possible". Which task should the RN delegate to the LPN? 1. Notifying the HCP 2. Checking the size of the child's pupils 3. Administering a Tylenol supp 4. Removing the child's extra blankets and clothing

4. Measures should be taken to lower the child's temperature, including removing extra blankets and clothing; this can be appropriately delegated to this LPN

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? 1. Immediately notify the HCP of the reduced NG returns 2. Administer an entiemetic medication listen on the client's medication administration record 3. Pull the NG tube out an inch to release it from suctioning against the wall of the stomach 4. Irrigate the NG and check to see if the fluid returns to the drainage-collection container

4. Nausea and minimal returns from the NG tube suggest possible occlusion of the tube. The tube should be irrigated per agency policy, or HCP's order, especially if the surgical area involved the GI system

The nurse is caring for the client who had a squamous cell carcinoma removed from the face. Which task should the nurse delegate to the experienced LPN? 1. Teaching the client about risks for squamous cell carcinoma 2. Demonstrating how to care for the surgical site at home 3. Assessing the surgical site for swelling, bleeding, or pain 4. Reinforcing the rationale for avoiding aspirin use for a week following surgery

4. Reinforcing information previously taught is within the LPN's scope of practice

The client on the mental health unit is displaying manic symptoms. Which intervention should be the nurse's priority for this client? 1. Applying restrains to protect the client from self-inflicted injury 2. Administering tranquilizing medication as prescribed by the HCP 3. Monitoring the client for signs and symptoms of physical exhaustion 4. Reducing all forms of stimulation in the client's environment

4. The client is in a highly distractible state and is likely to overreact to even the slightest stimuli. Manipulating the external environment will have the most therapeutic initial impact on the client's hyperactivity

The new nurse has been oriented to the PACU and is caring for the client who had general anesthesia. The charge nurse determines that the new nurse can correctly position the client in the PACU when making which observation? 1. Assists the client to the prone position when the client is nauseated 2. Places the client in the Trendelenburg position when hypotensive 3. Positions the newly admitted client supine with the head elevated 4. Turns the client side lying when the client arrives in the PACU

4. The client should initially be placed in the lateral side-lying position to keep the client's airway open and avoid aspiration

A 4-month-old infant with no previous health problems is being seen for a routine well child appointment. The senior student nurse, working with the RN, completes the infant's physical assessment and reports to the RN that the baby's pulse rate is 165 bpm and that the infant is awake and calm. Which action should the nurse take first in evaluating the accuracy of this assessment? 1. Immediately retake the infant's vital signs and perform a complete assessment 2. Notify the HCP of the abnormal HR finding and infant status 3. Advise the student to ask the parent if there is a family history of cardiovascular disease 4. Direct the student to compare the HR value with those obtained at previous clinic visits

4. The first action is to compare the value both to the norms for the infant's age group and to the infant's previous readings. A normal HR for an infant 1-11 months is 80-160 bpm. Environmental changes and stressors can cause temporary increase in HR

The parent brings the 2-year-old child into an urgent care setting with blistering burns due to sun exposure. Following an initial assessment, which action should be the nurse's priority? 1. Determine percent of burn injury 2. Administer an analgesic medication 3. Open the blisters for debridement 4. Apply cool compresses for 20 minutes

4. The first priority is to stop the burning process and relieve the pain. Cool compresses will accomplish both. Epidural burns, such as sunburns, are painful

The 15-month-old toddler with croup is placed in a prescribed mist oxygen tent. When assessing the toddler 2 hours later, the RN obtains an increased HR of 122 bpm and RR of 58. Which action should the nurse take next? 1. Notify the health care provider immediately of the child's vital signs 2. Ask the PCA to obtain a blood pressure while calling the charge nurse 3. With the assistance of the PCA, remove the child from the oxygen tent 4. Ask the PCA to obtain an oximeter to check to toddler's oxygen saturation

4. The increased respiratory rate an HR could be signs of progressive airway obstruction. The RN should stay with the toddler to assess the respiratory status and ask the PCA to retrieve an oximeter to determine the saturation level and degree of respiratory impairment

The nurse is working with the LPN who is helping care for the HIV-positive client with sever esophagitis caused by Candida albicans. Which action by the LPN requires the nurse to intervene immediately? 1. Suggests that the client might like to order chile con carne for the next meal 2. Places a "no visitors" sign on the door of the room at the client's request 3. Performs hand hygiene and puts on a mask and gown before entering the client's room 4. Gives the client a glass of water after administering nystatin oral suspension

4. The nurse should immediately intervene because nystatin should be administered by having the client swish the medication in the mouth and then swallow it; it should not be followed with anything to drink

The client is being treated for the severe depression and is receiving information regarding self-help groups. Which statement made by the client best reflects understanding of the priority goal for crisis intervention? 1. "I'm going to attend self-help group to learn how to best cope with stress" 2. "Stress causes my depression, and I must learn to deal with it effectively" 3. "I know to take my medication regularly as prescribed by my provider" 4. "I really think I can learn how to cope so that I can get my old life back"

4. The priority goal for crisis intervention should be the client's return to a pre-crisis level of functioning

The RN is working with the ancillary staff member on a mental health unit. The RN recognizes the need to provide further education regarding the scope of practice with the staff member offers to take which action? 1. Facilitate the smoking breaks earned by the various clients on the unit 2. Accompany the 25-year-old client with schizophrenia to an off-site eye appointment 3. Provide visual observation every 15 minutes for the client who expresses suicidal ideation 4. Determine whether restraints may be removed from the client who was acting aggressively

4. The scope of practice for ancillary staff does not include evaluation of client status/condition/behaviour. Determining whether the removal of the physical restraints is appropriate is not within the scope of ancillary staff

The client is in the emergency room with a nail gun injury to the hand incurred while remodeling an old barn. There is a strong odor of alcohol, and the client admits to having three beers during a 3-hour period. Which parameter is most important for the nurse to evaluate first? 1. Blood type 2. Time of last voiding 3. Current blood alcohol level 4. Date of last tetanus immunization

4. There is a strong risk of infection with clostridium tetani. The spores are present in soil, garden mold, and manure and enter the body through a traumatic or suppurative wound. Tetanus immune globulin is recommended when the client's history of tetanus immunization is not known