NCLEX RN EXAM PRACTICE QUESTIONS L/M

Which identifies accurate nursing documentation notation(s)? Select all that apply. 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1,2,5 Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?

1. Assalt Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1. "Cushing's syndrome is caused by excessive amounts of cortisol." 2. "Cushing's syndrome is caused by decreased amounts of aldosterone." 3. "Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4. "Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

1."Cushing's syndrome is caused by excessive amounts of cortisol." CUSHUNGS CORITSOL Cushing's syndrome is a condition caused by excessive amounts of cortisol. Options 2, 3, and 4 are inaccurate descriptions of this disorder.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.A client needing a bed bath 2.A client needing to ambulate 3.A client needing packed red blood cells 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode

1.A client needing a bed bath 2.A client needing to ambulate 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode APs can perform tasks that are noninvasive. Therefore, options 1, 2, 4, 5, and 6 are tasks that the AP can perform. The client in option 3 must be cared for by the registered nurse. Focus on the subject, the tasks that are appropriate to assign to APs. Think about the word noninvasive. This will direct you to the correct options.

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the assistive personnel (AP)? Select all that apply. 1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 4.Giving medications left by the nurse for the client to take 5.Assisting a client with a urinary drainage catheter into a chair 6.Obtaining a catheterized urinalysis and taking it to the laboratory

1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 5.Assisting a client with a urinary drainage catheter into a chair Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the AP; therefore, these options are incorrect. The remaining options identify activities that can be performed by the AP.

A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the assistive personnel (AP)? Select all that apply. 1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his or her transportation to home 4.Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5.Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids

1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his or her transportation to home Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. Based on the options provided, the most appropriate activities for a AP are noted in options 1, 2, and 3. These options do not include situations to indicate that these activities carry any risk. Because the client needs to eat lying flat, the client is at risk for aspiration. Care related to IV therapy needs to be done by a licensed nurse.

The registered nurse (RN) is planning her client assignments for the day. She has a licensed practical nurse and an assistive personnel (AP) on her team. Which task should the RN delegate to the AP? Empty a client's urinary catheter bag. 2.Instruct a client on his or her new diabetic diet. 3.Teach a client how to check her or his blood glucose. 4.Evaluate a newly admitted client's home medications.

1.Empty a client's urinary catheter bag. The nurse must delegate tasks according to the educational level of staff members. Unlicensed personnel such as a AP can perform tasks that are noninvasive, such as emptying a urinary catheter bag. Additionally, APs are not trained to teach or evaluate. Only an RN can teach, evaluate, and instruct.

The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? 1.Organize, manage, and balance health care services needed for the client. 2.Report daily to all members of the client's health care team to advise them of the plans. 3.Plan weekly meetings with all persons involved in the care of this client to assess status. 4.Conduct daily teaching sessions for the client and significant others about the case management process.

1.Organize, manage, and balance health care services needed for the client. The role of the case manager is to organize, manage, and balance health care services needed for the client. Although options 2, 3, and 4 may be aspects of the role of the case manager, the correct option identifies the overall role.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? 1.Place the client in a side-lying position. 2.Initiate wound care protocol for standardized ulcer care. 3.Meet with the wound specialist to identify measures to improve healing. 4.Determine which treatments would best meet the healing needs of the client.

1.Place the client in a side-lying position The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities

1.The acuity level of the clients; 5.Client needs and workers' needs and abilities There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1.Libel 2.Battery 3.Assault 4.Slander 5.False imprisonment

2. Battery, 3. Assault, 5. False imprisonment False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the assistive personnel (AP)? 1.A client requiring dressing changes 2.A client requiring frequent temperature measurements 3.A client on a bowel management program requiring rectal suppositories and a daily enema 4.A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

2.A client requiring frequent temperature measurements Assignment of tasks to the AP needs to be made based on job description, level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. The client described in the correct option has needs that can be met by a AP.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1.Prepare the triage rooms. 2.Activate the emergency response plan. 3.Obtain additional supplies from the central supply department. 4.Obtain additional nursing staff to assist in treating the casualties.

2.Activate the emergency response plan. In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.

The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised? 1.Autocratic 2.Democratic 3.Situational 4.Laissez-faire

2.Democratic Democratic leadership is defined as participative, with a focus on the belief that all members of the group have input into the decision-making process. This leader acts as a resource and facilitator. Autocratic leadership dominates the group, with maintenance of strong control over the group. Situational leadership is based on the current events of the day. Laissez-faire leaders assume a passive approach, with the decision making left to the group.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms.

2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? 1.Determining if the client has consistently been medication compliant 2.Providing distraction for the client by engaging the client in a board game 3.Discussing the frequency and duration of the hallucinations with the client 4.Assisting the client in identifying any new stressors he or she may be experiencing

2.Providing distraction for the client by engaging the client in a board game Although all of the options represent appropriate interventions, APs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the AP. The other options, assessing medication compliance, the characteristics of the hallucinations, and stressors, are nursing responsibilities and may not be delegated to a AP. Note the strategic words, most appropriately. Focus on the subject, the task that can be delegated to the AP. Selecting the task that is most basic and unrelated to medical or nursing therapies will direct you to option 2.

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? 1.Administer 1 more enema. 2.Stop administering the enemas. 3.Continue to administer enemas until the solution is clear. 4.Wait for 1 hour and then continue administering the enemas.

2.Stop administering the enemas. Client preparation for a barium enema may include the administration of enemas before the test. If administering enemas until clear is prescribed on the morning of the test, enemas should be administered no more than 3 times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the medication room until help is obtained.

3. Call the nursing supervisor Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action. Note the strategic words, most appropriate. Eliminate option 4 first, because this is an inappropriate and unsafe action. Recall the lines of organizational structure to assist in directing you to the correct option.

A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1.A client is performing colostomy irrigations. 2.The client with a leg ulcer is demonstrating signs of wound healing. 3.A postoperative client is discharged home 1 day earlier than expected. 4.The client with diabetes mellitus is administering insulin injections appropriately.

3.A postoperative client is discharged home 1 day earlier than expected. Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The correct option is the only one that identifies a positive variance. Options 1, 2, and 4 demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance.

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? 1.A client who requires teaching about an insulin pump 2.Completing an admission assessment on a newly admitted client 3.Administration of a new oral medication to a client with Alzheimer's disease 4.An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

3.Administration of a new oral medication to a client with Alzheimer's disease Oral medication administration is within the scope of practice for an LPN. Teaching is the responsibility of the registered nurse (RN). Assessments are also done by the RN. The LPN's scope of practice is restricted to data collection.

The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? 1.Autocratic 2.Situational 3.Democratic 4.Laissez-faire

3.Democratic Democratic styles empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Situational leadership uses a style that depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision.

A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which action by the LPN requires follow-up by the RN? 1.The LPN keeps the client's knee at the hinged joint of the machine. 2.The LPN assesses the client for pressure areas at the knee and the groin. 3.The LPN places the client's knee in a slightly externally rotated position. 4.The LPN checks the degree of extension and flexion and the speed of the CPM machine according to the primary health care provider's (PHCP's) prescriptions.

3.The LPN places the client's knee in a slightly externally rotated position. In the use of a CPM machine, the leg should be kept in a neutral position and not rotated either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse should monitor for pressure areas at the knee and the groin and should follow the PHCP's prescriptions and institutional protocol regarding extension and flexion and the speed of the CPM machine.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1. The client receiving a heparin infusion 2. The client receiving a blood transfusion 3. The client receiving continuous oxygen at 2 L/min 4. The client recovering from Guillain-Barré syndrome 5. The client who just returned from surgery for a hip repair 6. The client on isolation for methicillin-resistant Staphylococcus aureus

3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 6.The client on isolation for methicillin-resistant Staphylococcus aureus APs cannot be assigned to a client requiring care that is more than basic. APs do not have the education to safely care for clients requiring more than basic care. Assigning a AP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN)

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign 4 clients and has 1 licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1 A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by a AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1.Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission

4. Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."

4."I will call the nursing supervisor to seek assistance regarding your request." Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriateassignment for the assistive personnel (AP)? 1.A client scheduled to receive a blood transfusion 2.A client with bladder cancer who will be receiving chemotherapy 3.A client newly diagnosed with diabetes mellitus scheduled for discharge 4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client on bed rest who requires ROM exercises. The AP is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require assessment skills that only a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and coordination of necessary home care services.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

4.A client requiring abdominal wound irrigations and dressing changes every 3 hours When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. LPN'S CAN NOT INITIATE ANYTHING

The nurse is planning the client assignments for a group of clients and has a licensed practical nurse (LPN) and an assistive personnel (AP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? 1.A client with stable heart failure who has early-stage Alzheimer's disease 2.A client who is scheduled for an electrocardiogram and a chest x-ray examination 3.A client who was treated for dehydration, is weak, and needs assistance with bathing 4.A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion

4.A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion The nurse would most appropriately assign the client with emphysema to the LPN. This client has an airway problem and has the highest priority needs among the clients presented in the options. The clients described in options 1, 2, and 3 can appropriately be cared for by the AP

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1.Ignore the resistance. 2.Exert coercion on the AP. 3.Provide a positive reward system for the AP. 4.Confront the AP to encourage verbalization of feelings regarding the change.

4.Confront the AP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the AP to find out when the last pain medication was given to the client. 3.Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client

1.Actual or life-threatening concerns Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.

The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? 1.Autocratic 2.Situational 3.Democratic 4.Laissez-faire

1.Autocratic The autocratic style of leadership is task oriented and directive. Situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and provides an opportunity to grow professionally. The laissez-faire style allows staff to work without assistance, direction, or supervision.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially?1.Contact the client's primary health care provider (PHCP). 2.Call the client's family to arrange for transportation. 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

1.Contact the client's primary health care provider (PHCP). In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the assistive personnel (AP)? 1.Orient the client to the hospital surroundings. 2.Instruct the client on how to apply the eye drops. 3.Listen to the client express his or her frustration or loss. 4.Review hand-washing and hygiene practices with the client.

1.Orient the client to the hospital surroundings. Orienting the client to the hospital room and surroundings is within the scope of the AP's responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to APs.

A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? 1."They are developed based on appropriate standards of care." 2."They are nursing care plans and use the steps of the nursing process." 3."They are developed through the collaborative efforts of members of the health care team." 4."They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."

2."They are nursing care plans and use the steps of the nursing process." Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. All other options appropriately describe the use of a critical path.

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two assistive personnel (AP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? 1.A client requiring frequent ambulation 2.A client scheduled for a cardiac catheterization 3.A client requiring range-of-motion (ROM) exercises 4.A client with a 24-hour urine collection who is on strict bed rest

2.A client scheduled for a cardiac catheterization The RN is legally responsible for client assignments and must assign tasks according to the guidelines of Nurse Practice Act and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The AP has been trained to care for a client on bed rest and on urine collection, provide assistance with ambulation, and perform ROM exercises. The RN would provide instructions to the AP regarding the tasks, but the tasks required for these clients are within the role description of a AP.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The victim who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the victim is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which bestaction? 1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing administration, and then call the hospital lawyer.

2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action. Note the strategic word, best. Eliminate option 1 first because of the word refuse. Next, eliminate options 3 and 4 because they are premature actions.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? 1. Requires that 1 nurse take care of 1 client 2. Promotes appropriate use of hospital personnel 3. Requires a case manager who plans the care for all clients 4. Uses a team approach, but 1 nurse supervises all other employees

2.Promotes appropriate use of hospital personnel Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources; its aim is to maximize hospital revenues while providing for optimal outcomes of care. Case management manages client care by managing the client care environment. Options 1, 3, and 4 are not characteristics of case management.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client? 1.Ambulate the client frequently. 2.Encourage a diet that is high in protein. 3.Remove the water pitcher from the bedside. 4.Monitor the client's temperature every 2 hours.

3.Remove the water pitcher from the bedside. The client with acute glomerulonephritis commonly experiences an excess of fluid volume and fatigue. Interventions include fluid restriction and monitoring weight, intake, and output. The diet is high in calories but low in protein. The client is placed on bed rest, or at least encouraged to rest, because there is a direct correlation between proteinuria and hematuria and increased activity levels. It is unnecessary to monitor the temperature as frequently as every 2 hours.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment. Note the strategic word, best. Also note that an emergency is present. Recalling that a delay in treatment for the purpose of obtaining informed consent could result in injury or death will direct you to the correct option.

The nurse is delegating the morning hygienic care of a man to the assistive personnel (AP). In reviewing the assigned tasks, the nurse should instruct the AP to use an electric razor for which client? 1.The client with severe pain related to osteoporosis 2.The client with hypokalemia related to diuretic therapy 3.The client with thrombocytopenia related to chemotherapy 4.The client with an elevated white blood cell count related to infection

3.The client with thrombocytopenia related to chemotherapy The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1. The informed consent does not need to be obtained. 2. The informed consent should be obtained from the family. 3. The informed consent needs to be obtained from the client. 4. The primary health care provider will provide the informed consent.

3.The informed consent needs to be obtained from the client. Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriatenursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes

4. every 30 min The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

When creating an assignment for a team consisting of 1 registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN? 1.A client requiring frequent temperature checks 2.A client requiring assistance with ambulation every 4 hours 3.A client on a mechanical ventilator requiring frequent assessment and suctioning 4.A client with a spinal cord injury requiring urinary catheterization every 6 hours

4.A client with a spinal cord injury requiring urinary catheterization every 6 hours When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the AP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN? 1.A client requiring frequent temperature checks 2.A client requiring assistance with ambulation every 4 hours 3.A client on a mechanical ventilator requiring frequent assessment and suctioning 4.A client with a spinal cord injury requiring urinary catheterization every 6 hours

4.A client with a spinal cord injury requiring urinary catheterization every 6 hours When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the AP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

4.A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse? 1.Manager 2.Educator 3.Advocate 4.Caregiver

4.Caregiver The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priorityintervention in the event of this occurrence is which action? 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

4.Move the victim to a safe area away from the snake and encourage the victim to rest. In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

3 A client who requires urine specimen collections the nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. 1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information.

2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information. Electronic health records (EHR) will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right-click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine

3,5 The nurses who have not had chickenpox or did not receive the varicella zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus or who did not receive the varicella zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3.Call the nursing supervisor and report the occurrence. 4.Call the laboratory and ask for the name of the individual who sent the photograph.

4.Call the laboratory and ask for the name of the individual who sent the photograph. Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker and is an abusive behavior. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1."I cannot discuss any client situation with you." 2."If you want to know about Carol, you need to ask her yourself." 3."Only because you're worried about a friend, I'll tell you that she is improving." 4."Being her friend, you know she is having a difficult time and deserves her privacy."

."I cannot discuss any client situation with you." The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the PHCP can be contacted. 4.Administer the recommended dose until the PHCP can be located.

1. contact the nursing supervisor If the PHCP writes a prescription that requires clarification, the nurse's responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? 1.Libel 2.Slander 3.Assault 4.Negligence

2. slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

3.A client who requires urine specimen collections The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed.

3. The client was found lying on the floor - The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse. HomeHelpCalculator Study Mode Question 1 of 186 ID: 0016 | 6.xml #16 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? Test-Taking Strategy(ies):Focus on the subject, documentation of events, and note the data in the question to select the correct option. Remember to focus on factual information when documenting, and avoid including interpretations. This will direct you to the correct option.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift

4.A client with asthma who requested a breathing treatment during the previous shift Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1.A client complaining of muscle aches, a headache, and history of seizures 2.A client who twisted her ankle when rollerblading and is requesting medication for pain 3.A client with a minor laceration on the index finger sustained while cutting an eggplant 4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.