Nur 004

Which principles of nursing care or resources are used to define the standards of professional nursing practice and to determine nursing negligence? Select all that apply. 1. Care given in good faith to the best of one's ability 2. Clinical practice statements of professional organizations 3. Nursing medical-surgical textbooks 4. The nurse's usual custom and practice 5. The state's Nurse Practice Act

2,3,5

The registered nurse is caring for multiple clients on a busy surgical unit and should delegate which action to the unlicensed assistive personnel? 1. Assist client, post hip fracture repair, to the bathroom 2. Check the appearance of client's wound 3. If client tolerates oral liquids, discontinue nasogastric tube 4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)

1

A client has a chest tube for hemopneumothorax. The chest tube is connected to wall suction at 20 cm of H2O. The registered nurse can delegate which action to unlicensed assistive personnel? 1. Checking the water seal chamber for the presence of an air leak 2. Measuring and documenting the amount of drainage every 4 hours 3. Milking the chest tube to remove clots from the tubing 4. Teaching the client to cough and deep breathe to facilitate drainage

2

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply. 1. Before liver biopsy, pulse is 80/min and blood pressure (BP) is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg 2. Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg 3. Client with coronary artery disease on metoprolol; pulse is 62/min 4. Elderly client with black stools; pulse is 112/min 5. Neonate crying inconsolably at feeding time; pulse is 160/min

1,4

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the registered nurse (RN) delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client in completing a health history form 2. Collecting a urine specimen for culture and sensitivity 3. Instructing the client to strain urine when voiding 4. Measuring and documenting urine output 5. Monitoring the color and characteristics of urine output

2,4

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? Select all that apply. 1. Financial power of attorney 2. Health care proxy 3. Life insurance beneficiary 4. Living will 5. Safe deposit box

2,4

The emergency department (ED) nurse is obligated to make a report for which situations? Select all that apply. 1. Report to a client's employer that the client had a car crash while intoxicated 2. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse 3. Report to the medical examiner a death following a trauma, even if the family refuses autopsy 4. Report to the spouse of a client that the client has a reportable sexually transmitted disease 5. Report to the supervisor that an oncoming physician has the smell of alcohol on the breath

2,3,5

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse in an irregular event? Select all that apply. 1. "Client found on floor this morning at 0650. No verbalized complaints. I think client tripped over a cord. Client instructed on safety during ambulation." 2. "Client reports IV pole hit head at 0730. Denies pain. IV pole removed for client safety. Will continue to monitor every hour. Health care provider (HCP) notified." 3. "Heparin infusion running at 15 units/kg/hr at 0715; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 0720, aPTT 65 sec. HCP notified and labs will be drawn again at 1320." 4. "IV site in right hand is red and swollen at 0930. IV removed, bleeding controlled, and warm compress administered at 0940. Will reassess for swelling and pain every hour." 5. "Package of green leaves found in client drawer at 1300. Client acting suspicious at 1400. HCP notified. Will call security. Client has multiple tattoos and piercings."

3,4

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule-out myocardial infarction 4. Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

1

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1,2

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply. 1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line 2. History of multiple sclerosis with ataxia and diplopia 3. One day postoperative from a hemicolectomy 4. Reporting abdominal pain with coffee ground emesis 5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value

1,2,5

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity

2

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? 1. Ask if the client can go without the oxygen for 2 hours 2. Delay discharge until the oxygen is delivered 3. Notify the health care provider (HCP) to see what action should be taken 4. Send a hospital oxygen tank home with the client

2

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1. Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker

2,3,4

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply. 1. Client diagnosed with lumbar spinal cord compression has paraplegia 2. Client's Glasgow Coma Scale (GCS) score is 3 3. Client is refusing a life-saving treatment due to religious beliefs 4. Client with intracerebral hemorrhage has aphasia 5. Oriented client has cancer and is on a ventilator

2,4

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms 3. 60-year-old with marked anemia reports shortness of breath when ambulating 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66)

1

The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? 1. Blunt head trauma with projectile vomiting 2. History of Alzheimer disease with agitation 3. History of carpal tunnel syndrome with hand numbness 4. History of third cranial nerve pathology with double vision

1

The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? 1. Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour 2. Client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tingling of the hand and fingers 3. Client 8 hours postoperative total knee arthroplasty who has 2 closed-wound suction drains and a total output of 200 mL sanguineous drainage 4. Male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L)

1

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline 2. 2 days postcoronary bypass graft surgery with a white blood cell (WBC) count of 18,000/mm3 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

1

The nurse receives report on the following 4 clients. Which client care should the nurse prioritize as first? 1. Client with a blood pressure of 210/126 mm Hg and nausea, vomiting, and headache 2. Client with 3 episodes of vomiting and abdominal cramps after eating potato salad at a camp party 3. Client with history of migraine and headache, nausea, and difficulty seeing bright light 4. Client with history of Mèniére disease and vertigo, nausea, and hearing loss

1

Which client should the nurse assess first? 1. A client in 3rd-degree heart block with a pulse of 42/min 2. A client with atrial fibrillation and a new warfarin order 3. A client with chronic obstructive pulmonary disease (COPD) with oxygen saturation of 91% 4. A client with postoperative pain rated 8 out of 10

1

The unit staff consists of a registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel (UAP). Which are the best tasks for the charge nurse to assign to the LPN? Select all that apply. 1. Administer a client's daily dose of subcutaneous heparin 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy 4. Reinforce teaching on self-administration of daily insulin to a new client with diabetes 5. Tally the shift's intake and outputs for the entire unit

1,2,4

Which of the following tasks can the registered nurse (RN) safely delegate to experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Ambulate an oxygen-dependent client to the bathroom 2. Check pulse oximetry for a client with respiratory rate 12/min 3. Instruct a client with pneumonia on usage of the incentive spirometer 4. Perform oral suctioning for a client with chronic obstructive pulmonary disease (COPD) 5. Turn and reposition a client with pneumonia

1,2,4,5

The unit is staffed with an experienced registered nurse (RN), an experienced licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following are appropriate to delegate to the LPN? Select all that apply. 1. Administer antispasmodic after a transurethral resection of the prostate 2. Administer heparin continuous infusion to a client with a venous thromboembolism 3. Assess bowel sounds 2 days after repair of an inguinal hernia 4. Discuss concerns about last shift's care with an irate family member 5. Teach Kegel exercises after a client has a catheter removed

1,3

The nurse is assisting the health care provider with a lumbar puncture in the client's room. The unit secretary calls over the intercom and tells the nurse that the laboratory is on the phone with a critical value report for one of the nurse's clients. What action should the nurse take? 1. Ask the unit secretary to write down a message from the laboratory personnel 2. Instruct the unit secretary to have the charge nurse receive the report 3. Leave the room to talk to the laboratory on the phone and then return immediately 4. Tell the unit secretary to have laboratory personnel send a written result

2

The nurse is making rounds on a medical/surgical floor. Which client should the nurse see first? 1. 32-year-old admitted for opioid withdrawal reporting severe generalized body pains 2. 34-year-old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain 3. 42-year-old admitted with acute pyelonephritis who needs a first dose of IV antibiotic 4. 67-year-old admitted with hepatic encephalopathy who needs a first dose of lactulose

2

The nurse is monitoring a client recovering overnight from femoral angioplasty and observes that his leg has become pale and cool to the touch. After paging the health care provider for an emergency evaluation, the nurse receives an angry telephone call asking why he always gets paged by this department at 2 AM with bogus consults. Which response by the nurse would be the most appropriate? 1. "How would you feel if it was your father not getting the medical care he needed?" 2. "I am worried that this man may lose his leg unless something is done immediately." 3. "I'm sorry, but it is hospital policy to report all postoperative complications to the health care provider on call. May I ask what's been bothering you about this department's pages?" 4. "Your behavior at this time is extremely unprofessional and I will be making a formal report to my supervisor."

2

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which is the most appropriate action by the nurse? 1. Act as a witness for the informed consent process 2. Provide additional information about what the client can expect 3. Report the surgeon to the ethics board for using an inappropriate consent process 4. Talk to the surgeon privately about using a trained Spanish-language medical interpreter

4

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? 1. Ask a client if the UAP has performed the test 2. Discuss the importance of task completion and accurate documentation in a staff meeting 3. Give the UAP a verbal warning not to falsify data 4. Take a client's capillary glucose personally and compare it to the recorded result

4

A masked man with a gun enters the hospital lobby and starts shooting. The police are able to secure the scene by wounding the shooter. In the emergency department, the nurse triages victims. Which victim should the nurse care for first? 1. A child with a head wound with brain tissue on ground, Glasgow Coma Scale (GCS) score "3" 2. A young client who has a gunshot wound in the thigh 3. Adult client reporting anxiety, lightheadedness, and tingling with respirations 40/min 4. The shooter who has an abdominal gunshot wound

4

Which issue would a unit quality improvement committee address? 1. A 10% decrease in client satisfaction in the registration process 2. A nurse who made 3 medication errors in the past quarter 3. An increase in catheter-associated urinary tract infections 4. Staff perception of hospital laboratory personnel incivility

3

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? 1. "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems." 2. "I will talk with the HCP about your concerns, but in the meantime it's important that you stay here." 3. "It's important that you stay in the hospital so that we can treat you quickly if you have problems." 4. "You have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now."

1

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a Do Not Resuscitate (DNR) prescription posted in the client's chart. Which action is correct? 1. Stop all resuscitation activity immediately 2. Continue resuscitation until DNR status is verified with health care provider 3. If client shows any signs of life, follow advanced cardiovascular support protocol until stable 4. Once resuscitation has begun, complete it regardless of client code status

1

A nurse delegates a task to the unlicensed assistive personnel (UAP). The UAP states, "I can't do that." Which is the best initial response for the nurse to make? 1. Ask the UAP the reason for the response 2. Do the task, but discuss the UAP's response with the manager 3. Ignore the UAP's initial response and repeat the delegation request 4. Remind the UAP of the importance of teamwork

1

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS use

1

A spouse calls the nurse at a clinic where the family has an established provider-patient relationship. The spouse reports that the partner is not feeling well and is concerned that something is seriously wrong with this client. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same-day appointment to the client 4. Tell the spouse to have the client call the nurse

1

The nurse has just received report. Which client should the nurse assess first? 1. Client admitted from coronary angiography in the past hour with back pain 2. Client with a deep vein thrombosis (DVT) on heparin drip at 1250 units/hr with an activated partial thromboplastin time (aPTT) of 60 seconds 3. Client with a head injury and a Glasgow Coma Scale of 14 4. Postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale

1

The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min

1

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness 2. 11-year-old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin

1

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

1

The nurse receives report on 4 pediatric clients in the emergency department. Which client should be seen first? 1. 3-week-old with fever who is sleeping more than usual and refuses to feed 2. 4-month-old who has painless, new-onset, bilateral testicular swelling 3. 8-month-old who ingested a bottle of bubble soap 30 minutes ago 4. 2-year-old with fever, runny nose, cough, and sore throat for the past 2 days

1

The registered nurse (RN) is caring for a postoperative client with a Hemovac drain. Which task is inappropriate for the RN to ask the experienced unlicensed assistive personnel (UAP) to perform? 1. "Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client." 2. "Please measure the Hemovac drainage at 2:00 PM and let me know how much there was." 3. "Please record the amount of the Hemovac drainage on the intake and output record at the end of the shift." 4. "Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught."

1

The registered nurse (RN) is working with unlicensed assistive personnel (UAP). Which task can the RN safely delegate to the UAP? 1. Assisting a 2-day postoperative hip arthroplasty client with morning care 2. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter 3. Initial change of colostomy bag for a client who is 1-day postoperative colostomy 4. Refilling the empty enteral feeding container with tube feeding

1

Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site 2. Client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday 3. Client with atrial fibrillation and an irregular heart rate of 94/min 4. Client with dementia and Clostridium difficile (C difficile) who was incontinent of liquid stool

1

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all that apply. 1. "Elevate the right leg on two pillows." 2. "Measure client for compression stockings." 3. "Please let me know what the urine looks like." 4. "Tell me what the client eats at lunch." 5. "Verify wrist restraints are on correctly."

1,4

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1. Accepting a birthday gift of a gold bracelet from a client 2. Making a visit to the hospital after a client has surgery 3. Offering to pray together if a client so wishes 4. Sending a sympathy card to family after a client dies 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client

1,5,6

The pediatric nurse receives report on 4 clients. Which client should the nurse see first? 1. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside 2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside 3. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside 4. An 11-year-old scheduled for ear surgery today; no parents are at the bedside

2

The registered nurse (RN) prepares to give out client care assignments. Which client is appropriate for the RN to assign to the licensed practical nurse (LPN)? 1. Client admitted 3 hours ago with suspected acute pancreatitis 2. Client who had a total right hip replacement 2 days ago 3. Client who had a total thyroidectomy 2 hours ago 4. Client with alcohol withdrawal syndrome

2

Which client should the charge nurse assign to the room closest to the nurses' station? 1. Client with a Salem sump tube to continuous suction who is deaf 2. Client with gastroenteritis and dementia who wanders 3. Client with herpes zoster under airborne isolation precautions 4. Client with sickle cell crisis who requires frequent intravenous opioids

2

After the change of shift, a group of clients is assigned to the nurse. Which client should the nurse assess first? 1. Client 1-day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site 2. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago 3. Client with COPD exacerbation who is receiving bi-level positive airway pressure (BIPAP) therapy and has a pulse oximetry reading of 90% 4. Client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics

2

An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? 1. Call the telemetry unit manager 2. Notify the nursing supervisor 3. Send the client to ICU to "hold" the client in the hallway 4. Wait until the resident has time to request the transfer

2

An emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Five-year-old with a superficial leg laceration 2. Lethargic 3-month-old with diarrhea for the past 12 hours 3. Seven-year-old with a elevated temperature of 101 F (38.3 C) and hematuria 4. Seventeen-year-old with severe, acute abdominal pain

2

Multiple clients present to the emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care? 1. 26-year-old IV drug user reporting fever and right arm redness and swelling 2. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains 3. 69-year-old with diverticulosis reporting left lower quadrant pain and fever 4. 74-year-old with right knee replacement reporting fever and right knee swelling

2

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? 1. "I will get this notarized as soon as I can." 2. "I will give a copy of this to my daughter, who is listed as my health care proxy." 3. "I'll put this on my refrigerator, so no one will give me cardiopulmonary resuscitation (CPR)." 4. "You and my daughter can witness this for me."

2

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? 1. A 6-month-old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness 2. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen 3. A 4-year-old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply 4. A 15-year-old whose eyes are red and itchy and have a yellow discharge

2

The infection control nurse is observing a new graduate nurse in the intensive care unit. Which action by the new nurse would require additional orientation by the infection control nurse? 1. Remove gloves prior to removing isolation gown 2. Use a nail brush to scrub underneath artificial nails 3. Use alcohol-based hand sanitizer instead of washing hands when entering and exiting client room 4. Wash hands and do not wear gloves when preparing medications in the med room

2

The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospital's legal team 4. Report the incident to the state medical board

2

The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

2

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. "I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset."

2

The unit's staff includes an experienced registered nurse, a licensed practical nurse, and unlicensed assistive personnel. Which tasks can the charge nurse delegate to the unlicensed assistive personnel? Select all that apply. 1. Ambulate independently a 1-day postoperative client with a chest tube 2. Measure output in wound drainage container and document on output flow sheet 3. Obtain unit of packed red blood cells from the blood bank to bring back to the unit 4. Report to the registered nurse if a client has redness and swelling at the IV insertion site 5. Take family members to the waiting room when the client goes into surgery

2,3,4,5

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply. 1. 2 UAPs repositioning a client who is comatose and has been on the left side for 3 hours 2. 2 UAPs using the log-rolling technique to move a stable client with a cervical collar 3. 3 UAPs pulling up a client in bed who weighs 331 lb (150 kg) 4. UAP assisting a client with a position change who is 8 hours post hip replacement surgery 5. UAP using a gait belt while transferring a partial weight-bearing client from the bed to a chair

2,4

There is a motor vehicle crash, and a nurse stops to help. A victim has a laceration with spurting blood. The nurse is not covered by the Good Samaritan Act if which of the following criteria are involved? Select all that apply. 1. The client dies 2. The nurse accepts money 3. The nurse does not accompany the client to the hospital 4. The nurse does not apply direct pressure to the artery 5. The nurse knows the client

2,4

The charge nurse on a medical unit makes assignments for the nursing team composed of a registered nurse (RN), 2 licensed practical nurses (LPNs), and a student nurse (SN). Which assignment is the most appropriate? 1. LPN assigned to a client with a gastrointestinal bleed and hypotension who is receiving blood and requires vital sign monitoring every hour 2. LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain 3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit 4. SN assigned to a client with multiple sclerosis and dysphagia who requires multiple oral and IV medications

3

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assessfirst? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dL (38.3 mmol/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days

3

A visitor at a hospital reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What response should the nurse make? 1. Encourage the visitor to see if lying down helps 2. Instruct the visitor to call the primary health care provider (HCP) 3. Offer to take the visitor to the emergency department (ED) 4. Proceed to take the visitor's blood pressure

3

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the registered nurse. Which statement would be the most appropriate response? 1. "I'll talk with the client to see why the client is angry." 2. "It sounds like you shouldn't work with this client, so I will reassign you." 3. "Let's go together to ask about the client's concerns." 4. "Why don't you go talk with the client about why the client is angry?"

3

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? 1. Administer the correct medication and obtain current vital signs 2. Alert the graduate nurse and complete an incident report 3. Assess the client and notify the health care provider 4. Discontinue the dopamine and inform the nursing supervisor

3

The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an International Normalized Ratio of 4.0 who has a warfarin dose due 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and has a dose of vancomycin due 3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

3

The client diagnosed with terminal metastatic cancer asks the nurse for assistance in committing suicide. The nurse personally believes that assisted suicide is a client's right. How should the nurse respond? 1. A physician prescription would be required for the nurse to participate 2. Clarify that the client must put these wishes in writing 3. Nursing's code of ethics prohibits the nurse's involvement 4. Tell the client that nurses can legally assist suicide only in a few states

3

The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation? 1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives 2. Tape-record a report and leave a cell phone number to call if there are any questions 3. Tell the charge nurse of the impending need to leave and that client coverage is required 4. Write out a report about the clients for the incoming nurse prior to leaving

3

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

3

The nurse calls the health care provider at midnight and states, "Client X in room 212 had a colectomy yesterday and is now lethargic. The client currently has a rising pulse at 130/min and a falling systolic blood pressure at 80 mm Hg. I am concerned that the client is going into shock." With regard to the SBAR (Situation, Background, Assessment, and Recommendation/Request) communication technique, what is the most important information excluded by the nurse? 1. Basic demographic information 2. Current temperature and trend 3. Requesting action by the health care provider 4. Significant past medical history and allergies

3

The nurse notifies the health care provider of a change in client condition. Which of the following reports given by the nurse includes the most appropriate and completeinformation? 1. "A 43-year-old client with pneumonia in room 343 has wheezing, crackles, and diminished breath sounds. Temperature is 101.2 F (38.4 C), respirations are 36/min, and pulse oximeter shows 90%. I think the client may need arterial blood gas testing." 2. "A 75-year-old client in room 474 is in respiratory distress. The respiratory therapist (RT) gave a breathing treatment, but the client is deteriorating rapidly. The RT did not hear left side breath sounds and recommends a chest x-ray." 3. "An 80-year-old client in room 234 with a history of heart failure was admitted today for pneumonia and is receiving oxygen and antibiotics. The client is dyspneic and restless, and oxygen saturation is now 89%. Would you like me to increase the oxygen flow rate?" 4. "The client with pneumonia in room 265 is reporting shortness of breath. The RT gave the client a breathing treatment 30 minutes ago, but the client is no better. Would you like to prescribe any laboratory tests or make any changes to the treatment?"

3

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis 2. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine 3. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL (27.8 mmol/L) who is to receive subcutaneous regular insulin and insulin glargine

3

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? 1. Client with anemia who began receiving a unit of packed red blood cells 1 hour ago 2. Client with hemoglobin of 7 g/dL (70 g/L) who needs to be started on IV iron therapy 3. Client with seizure activity who received lorazepam 20 minutes ago 4. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour

3

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Alert the x-ray department about maintaining airborne isolation precautions 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room 5. Talk with the family about the reasons for airborne isolation precautions in the client

3,4

Which of the following findings reflect concerning vital signs that require further nursing assessment and intervention? Select all that apply. 1. After albuterol administration, 5-year-old client reports tremor and has pulse 120/min 2. After hydromorphone 1 mg intravenous push (IVP), BP decreases from 130/80 mm Hg to 110/70 mm Hg 3. Client receiving blood transfusion; pre-infusion: BP 120/80 mm Hg and pulse 80/min; now: 90/70 mm Hg and 100/min 4. Fetal heart rate monitored during labor changes from 140/min to 100/min with decelerations 5. Nurse preparing to administer prescribed nifedipine; blood pressure is 90/60 mm Hg

3,4,5

The registered nurse, licensed practical nurse (LPN), and unlicensed assistive personnel are assigned a client who is being transferred from the post-anesthesia care unit (PACU). Which tasks are the most appropriate to delegate to the LPN? Select all that apply. 1. Assess the client on admission 2. Measure vital signs and pulse oximetry 3. Monitor pain level and administer pain medications 4. Receive verbal report from the PACU nurse 5. Reposition client every 2 hours 6. Titrate oxygen based on unit protocols

3,6

Which nursing actions related to the care of colostomies may the registered nurse delegate to the licensed practical nurse? Select all that apply. 1. Assessment of the skin around the ostomy 2. Client and family education relating to ostomy care 3. Client assistance with application of the pouch 4. Documentation of stoma appearance 5. Initial irrigation of postoperative descending colostomy 6. Monitoring ostomy drainage and emptying of the pouch

3,6

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? 1. 22-year-old with sickle cell anemia admitted for acute pain crisis 2. 26-year-old with pneumonia reporting sharp right side chest pain on deep inspiration 3. 55-year-old who is 1-day postoperative bowel resection reporting pain at the incision site 4. 67-year-old with obstructive sleep apnea reporting pain at the fractured right tibia

4

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first? 1. Client with a history of thyroidectomy who needs a refill for levothyroxine 2. Client with Addison disease who is taking corticosteroids and reports new mood swings 3. Client with diabetes who reports blood sugars of 250-300 mg/dL (13.9-16.7 mmol/L) in the past week 4. Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C)

4

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client? 1. Clinical psychologist 2. Occupational therapist 3. Physical therapist 4. Social worker

4

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy 2. Document the spouse's statement in the client's chart 3. Notify the emergency department physician 4. Request that the spouse tell the client to call back

4

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the bestinitial reaction by the nurse? 1. Firmly indicate that the HCP cannot speak to the nurse in that manner 2. Immediately apologize and attempt to fix the situation 3. Say nothing and let the HCP vent frustrations 4. State that the conversation needs to take place in private and walk to a room

4

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Assess the employee's blood pressure 3. Check for allergies to drugs before giving acetaminophen from hospital stock 4. Refer employee to the employee health provider

4

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims come to the triage area. Which client would the nurse care for first? 1. Charred leathery skin over entire back, chest, and legs 2. Client shivering from sitting in water until rescued 3. Diabetic client who was unable to take insulin today 4. High-pitched, crowing inspiratory respirations

4

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent is required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

4

A 2-year-old child seen in the emergency department is assessed as being dehydrated and malnourished. The child's parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse? 1. The parent cannot stay at the hospital due to potential job loss if late for work 2. The parent does not seem to be concerned about the child's condition 3. The parent is single 4. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old

4

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment? 1. Adult protective services 2. Physical therapist 3. Physician 4. Social worker

4

A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first? 1. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C) 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours

4

A tornado hit the local town and many buildings have collapsed. Multiple victims are brought to the emergency department. Which client would the nurse assess first? 1. Child with history of asthma, partial-thickness burn on forearm and hand 2. Client had a large beam on back, cannot feel or move lower legs 3. Client has brick imbedded in skull, Cheyne-Stokes breathing, and 10-mm pupils 4. Client with shortened, externally rotated leg with thready pulse of 120/min

4

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggests the transfer of which client to the health care provider? 1. 52-year-old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels 2. 60-year-old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem 3. 65-year-old admitted last night for third-degree heart block who is awaiting permanent pacemaker placement 4. 78-year-old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

4

The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? 1. A licensed practical nurse (LPN) assigned to a client receiving blood transfusions 2. A student nurse assigned to a client who requires frequent intravenous pain medication 3. An LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today 4. An RN assigned to a client 1 day postoperative repair of a compound fracture

4

The client has metastatic cancer, and a living will on record indicates that the client does not want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency department with respirations of 4/min and a heart rate of 20/min. How should the nurse handle the situation at this time? 1. Ambu bag the client with a bag-valve-mask apparatus 2. Ask the client if the client has had a change of mind 3. Find out who is designated as the client's durable power of attorney for health care 4. Provide comfort measures

4

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated fromthe orthopedic unit to the medical unit? 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

4

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you."

4

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? 1. UAP applies the anti-embolism stockings while maintaining the client in supine position 2. UAP carefully smoothes out any wrinkles over the length of the stockings 3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot 4. UAP rolls down and folds over the excess material at the top of the stockings

4

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1-day post tubal myringotomy client with purulent tympanic drainage 2. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae 3. A 10-day-old client with a patent ductus arteriosus who has a continuous murmur 4. A 6-year-old client with epiglottitis who is drooling and has a severe sore throat

4

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client? 1. The client's sibling 2. The client's spouse 3. The health care provider (HCP) 4. The health care proxy

4

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? 1. A 25-year-old client with multiple sclerosis who had bladder incontinence last night 2. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes 3. A 58-year-old client with Parkinson disease who is drooling 4. A 78-year-old client with dementia who has new-onset agitation and confusion

4

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition

4

The nurse verifies a signed informed consent for an inguinal hernia repair. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. What nursing action needs to be completed? 1. Document that an additional hernia was found and will require surgery at a later time 2. Explain the need for additional repair to the client's family member before proceeding 3. Witness a signed consent for the added procedure after the client is awake 4. Witness a signed consent for the new procedure immediately with a family member

4

The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. Personally go and auscultate the client's lungs

4

The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff

4

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit? 1. Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist 2. Client 3-days post knee replacement surgery awaiting discharge 3. Client who is scheduled for an above-the-knee amputation today 4. Client with a long leg cast applied yesterday morning to treat a fractured ankle

4

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse? 1. "Would you mind answering the lights anyway?" 2. "I need you to answer the lights because we want to provide good client care." 3. Say nothing and answer the lights, but write up a disciplinary action 4. Tell the UAP that this is unacceptable and speak to the nurse manager.

2

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initialresponse? 1. Apologize for the previous nurse's treatment 2. Ask the client to describe what happened last night 3. Explain that the night nurse was probably busy 4. Reassure the client that things will be better today

2

Multiple clients present to the emergency department. Which client should the triage nurse prioritize for additional diagnostic testing and definitive treatment? 1. Client at 11 weeks gestation with productive yellow phlegm cough but no abdominal pain 2. Client with Alzheimer disease who developed restlessness and confusion today 3. Client with deformed forearm who has normal circulation, movement, and sensation; pain rated "8" 4. Client with epilepsy who had a seizure at work today but is now alert and oriented

2

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate? 1. 3-year-old with a temperature of 102.4 F (39.1 C) who had a seizure at home 30 minutes ago and is very irritable 2. 8-year-old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale 3. 32-year-old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best 4. 72-year-old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

2

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager 2. Tell the HCP to stop the comments 3. Walk away and say nothing 4. Write up an incident report

2

The nurse practicing on a medical surgical unit cares for a client with type I diabetes mellitus. Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP)? 1. Assess the client for signs and symptoms of hypoglycemia 2. Check the blood glucose before meals and report it to the primary nurse 3. Teach the client to cut toenails straight across and file with rounded curves of the toes 4. Update the care plan to include client's preference for nighttime diabetic snack

2

After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)

2

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement? 1. Ask the transplant team to place a palliative care referral so the client can learn about the option of hospice instead of transplant 2. Assess the client's motivation to make the necessary self-care changes before and after the transplant 3. Schedule a meeting to enlist the help of family members in encouraging the client to stay sober until the transplant 4. Tell the nurse manager that the client may not be an appropriate transplant candidate

2

The nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action? 1. Ask the UAP to take the postoperative client's vital signs and report back immediately 2. Direct the UAP to ask the client to rate the pain on a scale of 0-10 and report back immediately 3. Direct the UAP to tell the client that you will be there shortly, and complete the sterile dressing change 4. Interrupt the dressing change to medicate the postoperative client

3

The nurse is leaving at the end of the shift on an elevator crowded with visitors. A health care provider (HCP) gets on the elevator and asks, "How is my client Mrs. Jones in Room 312 doing?" Which of the following is the best response to the HCP's question? 1. "I don't know because I am off duty." 2. "Mrs. Jones was fine when I last saw her." 3. "Why don't we step off the elevator and discuss it." 4. "You will have to talk to Nurse Smith, who is her nurse now."

3

A nurse notices that a client who is 1-day postoperative knee replacement surgery has a cool numb foot with a weak peripheral pulse. The nurse pages and asks the health care provider (HCP) to come see the client. The HCP states that the client's foot has been like that since surgery and that there is no need to come. Under the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) process, what step should the nurse take next? 1. Continue to assess the foot hourly 2. Document the HCP's statement 3. Elevate the affected leg on a pillow 4. Repeat request for HCP to come

4

A staff nurse automatically takes a lunch break first every day instead of asking other staff nurses about their preferences. Another nurse would like to take the first lunch break time sometimes. Which is the best way for the staff nurse to handle the situation initially? 1. Ask the nurse manager to talk to the nurse who takes the first break time 2. Poll the other staff nurses to see what they think about the situation 3. Realize that some matters are not worth bringing up and say nothing 4. Tell the nurse directly of wanting to take the first lunch break sometimes

4

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP) 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night

4

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers? 1. Decreased length of hospital stay 2. Less obvious needs of clients met accordingly 3. Properly educated clients 4. Reduced number of medical errors

4

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was delegated to the unlicensed assistive personnel (UAP) by the registered nurse (RN). At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first? 1. Ask the UAP about the situation 2. Inform the nurse manager 3. Perform the test 4. Review the fingerstick procedure with the UAP

1

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order

1,2,3

The charge nurse supervising a graduate nurse would need to intervene when that nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply. 1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement 2. Advises the client transport technician, "This client has fragile bones due to cancer, so move the client very carefully." 3. Asks a client, "When were you diagnosed with diabetes?" during admission assessment in a semi-private room with the privacy curtain in place between beds 4. Interprets the results of a client's diagnostic testing to the unit clerk 5. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged

1,2,4

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5.Nonmaleficence is reporting abuse for a client with Alzheimer disease

1,4,5

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion (ROM) exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Remind the client to use the incentive spirometer 5. Reapply pneumatic compression device after bathing the client

1,4,5

A client is being transferred to another hospital for specialized care in their burn unit. What is the nurse required to do prior to transport under the Emergency Medical Treatment and Active Labor Act (EMTALA)? Select all that apply. 1. Call a report to the receiving nurse 2. Check if the client's family was notified of the transfer 3. Confirm that the client's primary health care provider (HCP) is on staff 4. Notify the client's insurance company 5. Verify that the receiving facility has available space and staff

1,5

The registered nurse is triaging pediatric clients in the emergency department. Which client is a priority for diagnostic testing and definitive care? 1. 4-year-old with right-sided abdominal mass reporting fatigue 2. 5-year-old with chronic constipation reporting abdominal pain and no bowel movement for 2 days 3. 10-year-old with sickle cell anemia reporting generalized pain of "10" and brownish urine 4. 13-year-old with type 1 diabetes reporting nausea, vomiting, and abdominal pain

4

The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place

2

The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP). The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? 1. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today 2. A 6-month-old who had diaphragmatic hernia repair 5 days ago 3. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm3 4. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing

2

Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%

2

A client with terminal cancer has named the sister as the durable power of attorney for health care (health care proxy). The client arrives unconscious at the emergency department with a heart rate of 20/min. The client's spouse and sister are present. How should the caregiving be handled? 1. Ask the spouse what should be done 2. Get directions about care from the sister 3. Immediately administer epinephrine 4. Provide only comfort measures

2

The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12-year-old with right lower quadrant abdominal pain that started in the periumbilical region 2. 14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16-year-old with sickle cell disease who has excruciating generalized body pain 4. 34-year-old with sudden-onset, right-sided flank pain radiating to the right groin

2

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

2

Which of the following are examples of violating the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule on privileged health information (PHI) confidentiality? Select all that apply. 1. A visitor talking in the waiting room states that the client is an alcoholic 2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells the hospital roommate that the client went for a gallbladder test 4. The registered nurse tells a visitor to wear a mask because the client is on airborne precautions 5. Two LPNs are discussing a cure for AIDS on a crowded elevator

2,3

The registered nurse (RN) is caring for a confused client in soft wrist restraints. Which tasks can the RN safely delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess circulation and sensation of the extremities 2. Perform range of motion (ROM) exercises 3. Reapply the restraints after toileting 4. Report changes in skin integrity to the RN 5. Turn and reposition the client in bed

2,3,4,5

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? 1. Client with alcohol withdrawal who needs IV lorazepam every 2 hours 2. Client with emphysema and an oxygen saturation of 89% on room air 3. Client with sickle cell crisis requiring IV morphine every 2 hours 4. Client with type 2 diabetes mellitus who needs discharge teaching

3

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? 1. Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm and pink skin 2. Client with a concussion from closed-head injury due to a fall, Glasgow Coma Scale score of 15, headache, and memory loss 3. Client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light 4. Client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr

3

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

4

A summary of an epidemiological study contains the following information. Over a five year period, students attending a suburban high school were screened for depression. During that five year period, total enrollment was 3020 students, 1375 students were screened, and 80 of those students screened positive for depression and began treatment. School authorities reported that 112 total students were being treated for depression over the course of study. What number of students represents the incidence of depression among students at this school during that five year period? 1. 3020 2. 1375 3. 112 4. 80

4

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1. Encourage the night nurse to provide the UAP with additional training 2. Indicate that it is the night nurse's job to deal with staff problems 3. Remind the night nurse that the UAP is doing the best job the UAP can 4. Suggest that the night nurse discuss concerns with the nurse manager

4

Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3. Middle-aged client with vaginal itching and white, curdlike discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face

4

The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first? 1. Client who has a migraine is reporting 10/10 pain and nausea 2. Client who is postictal after a seizure is drowsy and confused 3. Client with amyotrophic lateral sclerosis is experiencing dysarthria 4. Client with a Glasgow Coma Scale score of 9 is no longer responding when called

4

A licensed practical nurse is discussing some client findings with the registered nurse (RN). Which client would be the priority for the RN to assess? 1. 72-year-old client with pneumonia who is receiving intravenous fluids and has a new S3 heart sound 2. Client on metoprolol for hypertension with pulse of 54/min and blood pressure of 154/82 mm Hg 3. Client who is 8 hours postoperative hip arthroplasty with 205 mL drainage in the suction drain 4. Client with 345 mL gastric residual volume aspirated from a PEG tube before an enteral feed

1

Which of these clients should the nurse assess first? 1. A client who has shortness of breath from moderate pleural effusion and is waiting for thoracentesis 2. A client who just had a long leg cast applied and has severe pain despite a dose of morphine 3. A client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness 4. A sickle cell crisis client who has severe bone pain despite a dose of morphine

3

The nurse has received report on 4 clients. Which client should the nurse see first? 1. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated 2. Client scheduled for surgery in 2 hours who has questions about the procedure 3. Client who had a colostomy yesterday and now has a leaking colostomy bag 4. Client with a total hip replacement 3 days ago who reports no bowel movement in 2 days

1

The nurse in the emergency department receives 4 clients. Which client should the nurse see first? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions

1

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift

1,3,4,5

A staff nurse complains to the charge nurse that another nurse was rude today. Which is the best initial response by the charge nurse to the complaining nurse? 1. Encourage the nurse to speak to the other employee about the incident 2. Have both employees meet with the charge nurse and discuss their issues 3. Offer to counsel the other employee about the employee's inappropriate behavior 4. Tell the nurse to tell the offending employee that the nurse will not tolerate insolence

1

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding 3. Client with purulent drainage and crusting of the eyelid with vision unaffected 4. New parent who is crying and overwhelmed, and denies suicidal ideation

1

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gestures 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

1

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding 4. Teaching the client about home enteral feeding and gastrostomy tube care 5. Weighing the client using the bed scale

1,2,3

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply. 1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse 4. Say nothing but watch for impaired behavior 5. Tell the oncoming nurse that he/she is not fit for duty

1,2,3

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply. 1. Facilitating communication between health care providers (HCPs) 2. Obtaining health information from the client's nursing home 3. Reconciliation of home medications 4. Referral for home health after discharge 5. Visiting the client daily while hospitalized

1,2,4

The nurse is caring for a group of hospitalized clients. The nurse should notify the health care provider in the middle of the night when which event occurs with any client? Select all that apply. 1. Client found lying on the back on the floor 2. Decrease in muscle strength to 3/5 on right side only 3. Pulse 110/min; 1 hour after 2 mg morphine pulse is 90/min 4. Stat laboratory result of serum sodium 124 mEq/L (124 mmol/L) 5. Will refuse dialysis if prescribed

1,2,4

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

1,3,5

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1,4

A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be thefirst action by the nurse? 1. Cancel the procedure until a valid consent form is signed 2. Determine if the client meets legal requirements to sign the consent form 3. Locate the client's parent or guardian to sign the consent form 4. Verify that the consent is properly witnessed and send the client to surgery

2

Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural practices of the clients on their assigned unit. Which leadership strategy is bestfor the nurse manager to implement to assist the graduate nurses in developing cultural competency? 1. Assign the graduate nurses to a unit without cultural diversity until cultural competency is achieved 2. Provide the graduate nurses with a workshop designed to teach about cultures encountered at work 3. Request that the charge nurse assign the graduate nurses 2 culturally diverse clients each shift 4. Suggest that the graduate nurses research various cultures and provide an in-service to the staff

2

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? 1. Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days 2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating 3. Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot 4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning

2

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

2

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? 1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea 2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min 3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F (38.3 C) 4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

2

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply. 1. Client has a row of 3-inch circles down the back from "cupping" 2. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA) 3. RN thinks a teenage client's signs are from abuse, but the health care provider does not 4. RN thinks an elderly client's signs are from abuse but the client denies this 5. Syphilis is diagnosed in an 11-year-old who denies sexual activity

2,3,4,5

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber

3

The office nurse receives 4 telephone messages from clients. Which client should the nurse call back first? 1. 20-year-old college student who reports getting a ringlike, red bull's eye-shaped, itchy leg rash after hiking in the woods 2 days ago 2. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching 3. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago 4. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well

3

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially? 1. Discuss the need for UAP inservice education with the nurse manager 2. Give praise to the UAP for encouraging the client to walk the entire hall 3. Immediately lower the bag and speak privately to the UAP 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift

3

The registered nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which is the best client for the charge nurse to assign to the OB nurse? 1. Female client with a fractured pelvis who is 4 months pregnant 2. Female client with cytomegalovirus (CMV) pneumonia 3. Male client with an open bowel resection with a Foley catheter 4. Male client with history of Billroth II surgery who is septic

3

Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

4

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis 2. Client preparing for discharge after cesarean birth 3. Client showing disinterest in caring for the newborn 4. Client with hysterectomy after postpartum hemorrhage

4

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? 1. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees 2. Client admitted with multiple sclerosis exacerbation has scanning speech 3. Client with epilepsy puts on call light and reports having an aura 4. Client with fibromyalgia reports pain in the neck and shoulders

3

Which concepts are regarded both legally and morally as patient/client rights? Select all that apply. 1. Access to the client's test results in the medical record 2. Choosing who will be the client's nurse for the shift 3. Having the client's pain assessed and addressed appropriately 4. Knowing the name and position of the client's health care provider 5. Receiving any health care procedures the client wants

1,3,4

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L)

3

The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? 1. Client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis 2. Client with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies 3. Client with ulcerative colitis who has fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray 4. Nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction

3

The day nurse gives the hand-off report to the evening nurse. Which statements are most appropriate to include in the report? Select all that apply. 1. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 2. "The client just had acetaminophen 500 mg PO for headache with good relief." 3. "The continuous heparin infusion bag needs to be replaced at 2100." 4. "The last potassium level was 3.2 mEq/L, and potassium chloride was prescribed 30 minutes ago but has not yet arrived from the pharmacy." 5. "The social worker is scheduled to speak with the spouse about home care at 0900 tomorrow." 6. "The unlicensed assistive personnel bathed the client at 0700."

1,3,4,5

The registered nurse is working with a licensed vocational nurse and unlicensed assistive personnel. A client has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions are most appropriate for the registered nurse to assign to the licensed vocational nurse? Select all that apply. 1. Administer oral pain medication if client reports low back pain 2. Assist the client with the use of a urinal post-procedure 3. Check for bleeding at the catheter insertion site every 15 minutes 4. Perform post-procedure vital sign measurements 5. Review ECG for dysrhythmias

1,3

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? 1. Client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain 2. Client who is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago 4. Client with a kidney stone who is requesting pain medication for severe flank pain

1

An unaccompanied 16-year-old female comes to the emergency department with severe abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120 /min and is lethargic. The parents are out of town, and no guardians could be reached. How should the care be handled? 1. Administer care until parents or guardians can be reached 2. Keep the minor but without giving care until parents or guardians can be reached 3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor 4. Provide health care and follow-up advice but do not give any direct care

1

The nurse is caring for a client with chronic pain who just had surgery and is receiving patient-controlled analgesia (PCA) morphine. The client is in severe pain, with a rating of 10/10, despite receiving the maximum ordered dose. The nurse calls the health care provider, saying that the client is still having pain and recommending a higher PCA dose. Which nursing role is being implemented in this situation? 1. Advocate 2. Caregiver 3. Educator 4. Manager

1

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

1

The day nurse gets the following hand-off report from the night nurse. The nurse should assess which client first? 1. Client with cellulitis, medicated with hydromorphone IV 1 hour ago, reports pain of 6 on a scale of 0-10 2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit 24% (0.24), is short of breath with activity 3. Client with heart failure and bilateral pleural effusions with serum sodium of 133 mEq/L (133 mmol/L), is scheduled for a thoracentesis this morning 4. Client with pneumonia and reactive airway disease, developed increased shortness of breath and high-pitched wheezing 10 minutes ago

4

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first? 1. A client with an ileostomy bag that has leaked stool all over 2. A client with chronic obstructive pulmonary disease, diminished breath sounds, and SpO2 of 91% 3. A client with deep venous thrombosis who missed the last warfarin dose 4. A client with sepsis who is developing petechiae

4

Which of the following are violations of the Health Insurance Portability and Accountability Act (HIPAA) regarding confidentiality of privileged health information (PHI)? Select all that apply. 1. A pregnancy result is given to a husband without the wife's permission 2. The client overhears, through a privacy curtain, the registered nurse (RN) call report on someone 3. The RN calls the client by first and last name in the public waiting room 4. The RN tells the transporting tech that the client has breast cancer 5. Unlicensed assistive personnel tell the discharged client, "You take care now!"

1,4

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation

2

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse? 1. Explain that the client's depression is being treated with medications 2. Explain that the client's depression will not be relieved by a ritual 3. Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony 4. Tell the family that such practices are not allowed in the hospital

3

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply. 1. Acute head injury with Glasgow Coma Scale of 12 2. Admitted with cirrhosis of liver with oozing esophageal varices 3. Asthma exacerbation with peak flow at 85% of personal best 4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 × 109/L) 5. Myasthenia gravis with ptosis in the evening

3,5

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours 2. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic 3. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

4

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need surgery?" What is the most appropriate action? 1. Call the nursing supervisor 2. Call the operating room scheduler and cancel the surgery 3. Page the health care provider and request clarification on behalf of the client 4. Report the incident to hospital administration

3

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL (190 g/L) 3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 × 109/L) 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)

1

The registered nurse (RN) is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client to the bathroom 2. Deciding if supplemental oxygen is necessary when the client is ambulating 3. Documenting vital signs in the electronic medical record 4. Notifying the nurse immediately if the client's respirations exceed 20/min 5. Reapplying the nasal cannula if it accidentally comes off

1,3,4,5

After talking to the client, the health care provider (HCP) tells the registered nurse that the client's signature is needed on the consent form that has been filled out. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take? 1. Call the HCP to come and talk to the client 2. Refuse to witness the signature on the consent 3. Teach the client about a low-fat diet 4. Tell the client that the HCP will explain it later

3

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools

3

The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain 4. 75-year-old with nausea, fever, and left lower quadrant pain

3

The nurse prepares to teach an in-service on legal issues related to nursing. Which legal terms are followed by an appropriate example? Select all that apply. 1. Assault: Threatening to administer a benzodiazepine if the client does not comply 2. Battery: Misinforming a client that a painful injection will not create discomfort 3. False imprisonment: Storing a competent client's clothes to prevent the client from leaving prior to a prescribed treatment 4. Informed consent: Calling the parent of an emancipated minor for approval prior to providing care 5. Invasion of privacy: Posting a medical update on the social media page of a client who is a friend

1,3,5

Which of the following are examples of medical battery? Select all that apply. 1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it 5. The nurse threatens to put a client in restraints if the client does not stay in bed

3,4

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? 1. Administer water enema to the 2-year-old with intussusception who has severe abdominal pain 2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever 3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement 4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding

4

The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

4

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days 3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches 4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain

4

The registered nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). Which tasks are most appropriate to assign to the LPN? Select all that apply. 1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 2. Assessing fluid volume status of a client with heart failure who is scheduled for discharge 3. Assisting with bathing, feeding, and dressing a client with multiple sclerosis 4. Performing wound care and sterile dressing change for a client with a stasis ulcer 5. Providing incontinence care and linen change for a client with diarrhea

1,4

Which are correct understandings of applying nursing ethical principles? Select all that apply. 1. Autonomy is requiring the client to have an advance directive 2. Beneficence is withholding prognosis from a client due to family wishes 3. Fidelity is administering medication as prescribed to the client 4. Justice is telling the client the truth that the biopsy is positive 5. Nonmaleficence is refusing to give report to a nurse who is impaired

3,5

The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate registered nurse (RN) during orientation. The LPN states, "The only difference between you and me is the size of our paychecks." What would be the best response for the new graduate RN to make initially? 1. Assert being the manager of the client team 2. Emphasize the additional education received 3. Explain the legal difference in the scope of practice 4. Focus on the need to work together for quality client care

4

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? 1. A 36-year-old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning 2. A 56-year-old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery 3. A 68-year-old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning 4. An 80-year-old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

3

The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing Against Medical Advice (AMA) papers 2. Discharging the child if parents have power of attorney papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy

3

The nurse on a medical unit is preparing to assess assigned clients after receiving change of shift report. Which client should the nurse assess first? 1. Client with Grave's disease and heart rate of 110/min 2. Client with pneumonia on day 3 of antibiotics needs a new IV line 3. Client with sickle cell disease who rates pain as 9 on a scale of 0-10 4. Client with type 2 diabetes and fingerstick glucose level of 220 mg/dL (12.2 mmol/L)

3

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 1. Client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain 2. Client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing 3. Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg 4. Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

3

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) 3. Administered warfarin to a client with International Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

3

Which client does the nurse assess first after receiving the morning report? 1. Client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now 2. Client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago 3. Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving 4. Client is 3 days postoperative total knee replacement; waiting to be discharged

3

Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)? 1. Assisting a client in ambulating to the bathroom for the first time following surgery 2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar of 70 mg/dL (3.9 mmol/L) 4. Taking vital signs every 15 minutes on a client who was just transferred from the post- anesthesia recovery unit

3

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and photophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge 4. Client with sudden onset of the "worst headache of my life"

4

The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? 1. Fell, twisting the right knee; heard a "pop" 2. History of glomerulonephritis; has "iced tea"-colored urine 3. Pain 10/10 in reddened eye; wears contact lens 4. Took a handful of amitriptyline tablets after a fight with spouse

4

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours 2. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms 3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria 4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

4

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 2. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

4

The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first? 1. Client receiving cyclophosphamide reporting bloody urine 2. Client who reports severe nausea and vomiting after chemotherapy 3. Client with an elbow abrasion and a lip laceration possibly requiring sutures 4. Homeless client who appears drowsy with a temperature of 95 F (35 C)

4

The nurse receives laboratory reports on 4 clients. Which report is most concerning and should be reported to the health care provider? 1. The client admitted with asthma exacerbation who has a PaCO2 of 32 mm Hg (4.26 kPa) 2. The client diagnosed with chronic obstructive pulmonary disease whose latest arterial blood gas shows a PaO2 of 85 mm Hg (11.33 kPa) 3. The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5 4. The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L)

4

The unit is staffed with an experienced registered nurse (RN), an experienced licensed practical nurse (LPN), and unlicensed assistive personnel (UAP). Which task can the charge nurse appropriately delegate to the UAP? Select all that apply. 1. Apply protective skin ointment after perineal cleansing 2. Determine if the client has adequate relief after administration of an analgesic 3. Document height and weight on a new admission 4. Feed a client who had a stroke (brain attack) 24 hours after admission 5. Perform passive range of motion exercises for client on a ventilator

1,3,5

Which of these tasks are appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Assign lunch times to the other UAP on the unit 2. Assist a client with a new ostomy with bathing and changing pouches 3. Collect vital signs on a client 4 hours after laparoscopic appendectomy 4. Pick up an intravenous antibiotic from the pharmacy 5. Record intake and output for a client with metabolic alkalosis

3,4,5