Delegation Health management

A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? A. vital signs B. intake and output C. height and weight D. allergy to iodine or shellfish

D. allergy to iodine or shellfish

A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action? A. Verify the symptoms with family. B. Inform social services. C. Ask the client about the client's drinking. D. Tell the client everything will be all right.

C. Ask the client about the client's drinking. Confirming suspicions directly with the client is the most reliable way to diagnosis and treat withdrawal symptoms.

True or False: An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task. True False

False

A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents? A. how to identify symptoms of UTI B. how to collect a midstream urine sample C. interventions to prevent UTIs D. risk factors for UTIs in children

C. interventions to prevent UTIs

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? A. Victim with an open fracture of the left lower extremity B. Victim who is crying hysterically and complaining of pain in the right ankle C. Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated D. Victim with an apparent chest wall defect and asymmetrical chest wall movement

D. Victim with an apparent chest wall defect and asymmetrical chest wall movement

A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? A. active bowel sounds B. adequate urine output C. orientation to the surroundings D. a patent airway

D. a patent airway After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs'airway, breathing, and circulation'must be assessed first.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure? A. Assess vital signs. B. Administer analgesics. C. Provide oral fluids. D. Reorient the client to the environment.

A. Assess vital signs. ECT is performed under sedation, so vital signs are monitored carefully for approximately one hour after the procedure or until the client is stable.

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours.

A. Assisting the patient to sit up on the side of the bed.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? A. Place an indwelling catheter. B. Monitor fetal heart tones. C. Perform a cervical examination. D. Prepare the client for cesarean birth.

B. Monitor fetal heart tones. Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae.

A three-year-old child brought to the emergency department is not breathing and is cyanotic. The parent states that the child has likely swallowed a penny. What is the nurse's first intervention? A. give 100% oxygen B. administer five back blows C. attempt a blind finger sweep D. administer abdominal thrusts

D. administer abdominal thrusts A child between the ages of one and eight should receive abdominal thrusts to help dislodge the object first. Administering 100% oxygen will not help if the airway is occluded.

A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? A. peer support through structured groups B. finding affordable housing for the group C. setting up a 24-hour crisis center and hotline D. meeting the basic needs to ensure that adequate food, shelter, and clothing are available

D. meeting the basic needs to ensure that adequate food, shelter, and clothing are available

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client? A. Managing pain B. Ambulating 50 feet C. Caring for the surgical wound D. Promoting nutrition

A. Managing pain

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

A. Place the client in a side-lying position.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priorityintervention? A. Have the parent give the child syrup of ipecac. B. Tell the parent to get the child to drink a glass of milk. C. Give the parent instructions on how to call poison control. D. Determine whether the parent knows cardiopulmonary resuscitation (CPR).

C. Give the parent instructions on how to call poison control.

The nurse working in the emergency department has four charts of clients who need to be assessed. Which client should be assessed first? A. An elderly client who has obvious signs of neglect B. A homeless client who has an open wound on his leg C. A client with cancer being admitted for chemotherapy D. A client with a history of schizophrenia threatening to harm himself

D. A client with a history of schizophrenia threatening to harm himself

The nurse is preparing to discharge a school-age child with asthma. Which intervention is mostimportant for the nurse to perform prior to discharge? A. Obtain additional equipment and medication that can be provided at the school. B. Arrange for a thorough, deep cleaning of the home. C. Discuss limitations on the child's participation in sports activities. D. Counsel the family in making arrangements to remove the family pet.

A. Obtain additional equipment and medication that can be provided at the school. The child needs to have equipment and medication available at school to treat and prevent asthma attacks

An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding? A. acute onset delirium B. temperature of 101.3°F (38.5°C) C. respiratory rate of 24 breaths/minute D. pleuritic chest pain and cough

A. acute onset delirium The acute change in client cognition (i.e., delirium) is considered a medical emergency and should be investigated immediately. This acute change could be evidence of sepsis, electrolyte imbalances, or other organic causes that should be diagnosed and treated as soon as possible. The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea, pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the nurse has treatments prescribed by the health care provider to address these findings.

A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labor is which of the following? A. assessing the uterine fundus and lochia B. checking the mother's temperature C. encouraging food and fluid intake D. providing privacy for the parents and their newborn infant

A. assessing the uterine fundus and lochia

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

B. A client scheduled for a cardiac catheterization

A client with an uncomplicated term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action? A. Prepare the woman for birth. B. Ask what time this happened and note the color, amount, and odor of the fluid. C. Immediately contact the provider. D. Collect a sample of the fluid for microbial analysis.

B. Ask what time this happened and note the color, amount, and odor of the fluid.

An amniotomy is performed on a client in labor. What is the priority nursing intervention following this procedure? A. Encourage the client to use breathing exercises as contractions increase. B. Assess fetal heart tones. C. Assist the client to ambulate to promote labor. D. Position the client on her left side.

B. Assess fetal heart tones. The nurse's priority is to assess fetal heart tones. When the amniotic membrane is ruptured, the umbilical cord may enter the birth canal with the gush of fluid and the presenting part may cause cord compression.

A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? A. diarrhea B. risk for aspiration C. risk for deficient fluid volume D. imbalanced nutrition, less than body requirements

B. risk for aspiration

What is the priority nursing assessment of a client with an eating disorder? A. cultural needs B. substance abuse history C. academic performance D. level of danger to self

D. level of danger to self

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. A. A confused older client who requires feeding B. A client who requires turning every 2 hours C. A client admitted with dehydration who is on strict intake and output D. A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% E. A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift F. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

A. A confused older client who requires feeding B. A client who requires turning every 2 hours C. A client admitted with dehydration who is on strict intake and output F. A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first? A. Assess the child's vital signs and neurological status. B. Establish intravenous access, and provide supplemental oxygen. C. Ask the parents what they think the child ingested. D. Interview the parents about the initial onset of symptoms.

A. Assess the child's vital signs and neurological status.

Which nursing intervention is a priority for an infant during the first 24 hours following surgery for cleft lip repair? A. Carefully clean the suture line after feedings to reduce the risk of infection. B. Position the infant in the prone position after feedings to promote drainage. C. Allow the infant to cry to promote lung expansion. D. Encourage the infant to use a pacifier to satisfy the urge to suck.

A. Carefully clean the suture line after feedings to reduce the risk of infection. The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn't be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

The nurse is caring for a client diagnosed with postoperative atelectasis. What intervention performed by the nurse best addresses the underlying pathophysiology that leads to atelectasis? A. Teach deep breathing, coughing, and incentive spirometry exercises. B. Provide supplemental oxygen as prescribed, and check oxygen saturation every hour. C. Mobilize the client in the hallway a minimum of three times per day as tolerated. D. Encourage adequate fluid intake to thin respiratory secretions.

A. Teach deep breathing, coughing, and incentive spirometry exercises. Atelectasis results from partial or full occlusion of bronchioles, which causes alveolar collapse. All the listed interventions can be used in these clients. Chest physiotherapy and incentive spirometry exercises work best to enhance the clearance of mucus and equalize pressure so alveoli can reinflate.

A nurse is developing a care plan for a family with a member who has anorexia nervosa. What is the most important information for the nurse to include? A. coping mechanisms that have been used in the past B. concerns about changes in lifestyle and daily activities C. rejection of feedback from family and significant others D. appropriate eating habits and social behaviors centering on eating

A. coping mechanisms that have been used in the past

The nurse is assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse? A. heart rate of 132 beats/min and blood pressure of 84/60 mm Hg B. oral temperature of 100.2° F (37.9º C) C. a gush of blood from the vagina when the client stands up D. reports of abdominal pain and cramping

A. heart rate of 132 beats/min and blood pressure of 84/60 mm Hg Tachycardia and hypotension may be signs of hemorrhage. An oral temperature of 100.2° F (37.9º C) may be due to dehydration, if it occurs on the first postpartum day. A gush of blood from the vagina when a client stands is a normal finding on the first postpartum day. Reports of abdominal pain and cramping are expected following cesarean birth.

A nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first? A. Administer IV fluids B. Administer IV naloxone C. Continue monitoring of vital signs D. Draw blood for a drug screen

B. Administer IV naloxone

The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse's priority action? A. Assessing serum potassium B. Assessing blood pressure C. Administering dextrose in water D. Administering opioids

B. Assessing blood pressure Removing a major source of adrenal hormones may cause a state of temporary adrenal insufficiency. After an adrenalectomy, the patient is usually sent to a critical care unit. Immediately after surgery, the patient should be assessed every 15 minutes for shock due to possible insufficient glucocorticoid replacement.

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention? A. Induce vomiting. B. Keep the child calm and relaxed. C. Administer activated charcoal. D. Monitor the parent-child interactions for possible child abuse.

B. Keep the child calm and relaxed. Keeping the child calm and relaxed will help prevent vomiting. If vomiting is induced, the esophagus will be damaged from regurgitation of the gastric poison. The risk of chemical pneumonitis exists if vomiting occurs. Activated charcoal poorly absorbs hydrocarbons, and it tends to distend the stomach and cause vomiting.

A client has a respiratory rate of 4 breaths/min. What are this nurse's priority assessments? A.Arterial blood gas (ABG) and breath sounds B. Level of consciousness and a pulse oximetry value C. Breath sounds and reflexes D. Pulse oximetry value and heart sounds

B. Level of consciousness and a pulse oximetry value

The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention? A. Watching for signs and symptoms of septic shock B. Maintaining adequate hydration C. Checking weight every three days D. Monitoring urine for specific gravity >1.030

B. Maintaining adequate hydration

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention? A. Position the client in the lithotomy position. B. Place the client on her left side and apply oxygen. C. Call the client's provider. D. Slow down the client's I.V. rate.

B. Place the client on her left side and apply oxygen. An FHR below 70 beats/minute is considered severe fetal bradycardia, and immediate interventions are needed. The nurse would first apply oxygen after positioning the client on her left side. Positioning the client in the lithotomy position is not indicated. Although the provider would be notified of the status change in the client, the nurse would not wait on orders from the provider to act. Slowing the I.V. rate would reduce the circulating volume of blood and worsen the problem.

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first? A. Prepare for imminent birth. B. Place the client on her left side. C. Administer oxygen by face mask. D. Increase the I.V. rate.

B. Place the client on her left side. Variable decelerations in fetal heart rate are caused by compression of the umbilical cord. Typically, variable decelerations are corrected by placing the client in a left lateral position to alleviate cord pressure

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child? A. Make a referral to the pediatric diabetes nurse. B. Prepare to administer intravenous fluids and insulin per order. C. Teach the family about the prevention of this complication of diabetes. D. Monitor the child closely in the emergency department before transfer to the medical unit.

B. Prepare to administer intravenous fluids and insulin per order.

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate? A. Continue monitoring per standards of care. B. Stop the magnesium sulfate infusion. C. Increase the infusion rate by 5 gtt/min. D. Decrease the infusion rate by 5 gtt/min.

B. Stop the magnesium sulfate infusion. Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if reflexes are diminished or absent, all of which are true for this client. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client's suppressed DTRs, low respiratory rate, and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.

A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? A. The leg in traction is kept externally rotated. B. The weights are allowed to hang freely over the end of the bed. C. The UAP instructs the client to perform ankle rotation exercises. D. The UAP lifts the weights while assisting the client as he moves up in bed.

B. The weights are allowed to hang freely over the end of the bed.

A nurse is caring for a 2-year-old client, who weighs 25 lb (11.3 kg), and has a fractured femur. What is the nurse's priority assessment for this client? A. length of one leg to the other B. affected leg distal to the fracture C. affected leg anterior to the fracture D. affected leg proximal to the fracture

B. affected leg distal to the fracture The nurse should focus the assessment on the area distal to the fracture. This area is most at risk for neurovascular compromise. If a fracture severs or obstructs blood vessels or nerves, blood flow is disrupted distal to the site, and may lead to nerve or tissue damage.

A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following? A. monitor the contraction pattern B. assess the fetal heart rate C. note the amount, color, and odor of the amniotic fluid D. check maternal vital signs

B. assess the fetal heart rate

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse? A. male client who is three days postoperative with an indwelling urinary catheter B. female in pelvic traction who is three months pregnant C. older adult woman who has been hospitalized for two days with herpes zoster D. male admitted for hearing voices commanding him to kill himself

B. female in pelvic traction who is three months pregnant Obstetric nurses may have limited experience with traction but will be able to offer the most support to the pregnant client if she has questions about the well-being of the fetus. The next best client to assign to the nurse is the postoperative male client with an indwelling catheter as the nurse should have experience caring for postoperative cesarean clients and urinary catheters. This nurse should not care for infectious clients; this presents the risk of disease transmission to those on her regular unit. This nurse has no experience with psychiatric clients.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A. A client with a history of recurrent candidiasis B. A client who had her first pregnancy before the age of 20 C. A client infected with the human papillomavirus (HPV) D. A client who has used oral contraceptives for 27 years

C. A client infected with the human papillomavirus (HPV)

A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first? A. Administer antibiotics B. Encourage bed rest C. Apply oxygen D. Assess nutritional intake

C. Apply oxygen

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child? A. Position the infant with the head elevated. B. Monitor intake and output. C. Assess respiratory status frequently. D. Incorporate parents into the child's care.

C. Assess respiratory status frequently. Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? A. Provide reassurance that the client is safe and the voices are not real. B. Provide reassurance that the client is safe and promise the staff will protect the client. C. Assess the nature of the commands by asking what the voices are saying. D. Administer a neuroleptic medication before speaking with the client.

C. Assess the nature of the commands by asking what the voices are saying. Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele? A. Keep the omphalocele dry. B. Cover the omphalocele when parents visit. C. Carefully position and handle the omphalocele. D. Gently palpate the omphalocele to assess for changes.

C. Carefully position and handle the omphalocele. Careful positioning and handling prevents infection and rupture of the omphalocele.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first? A. Cut off the client's clothing and dispose of it in hazardous waste containers. B. Place the fully clothed client in a shower for decontamination. C. Determine what decontamination measures took place in the field before approaching the client. D. Discharge or admit all current clients in the emergency department.

C. Determine what decontamination measures took place in the field before approaching the client.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? A. Limit fluid intake after 8 pm. B. Buy well-fitting walking shoes. C. Elevate the feet several times a day. D. Wear a pair of knee-high support hose.

C. Elevate the feet several times a day. Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out

The nurse is caring for a client with functional neurologic symptom disorder who has experienced pseudoseizures. What intervention is appropriate for the nurse to perform? A. Explain to the client that the pseudoseizures are not real seizures. B. Ignore the client's pseudoseizures to prevent reinforcement. C. Encourage the client to discuss feelings about the pseudoseizures. D. Administer a placebo as prescribed by the health care provider.

C. Encourage the client to discuss feelings about the pseudoseizures.

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client's body. What is the nurse's priority action? A. Notify the nursing supervisor. B. Notify the health care provider. C. Inquire how these bruises occurred. D. Document the findings.

C. Inquire how these bruises occurred. The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained.

Which nursing intervention is essential while caring for an infant with cleft lip or palate? A. Avoid encouraging breastfeeding. B. Cradle the infant horizontally while feeding. C. Involve the parents in feeding as soon as possible. D. Choose a regular nursery nipple for feedings.

C. Involve the parents in feeding as soon as possible. The sooner the parents become involved, the quicker they're able to determine the method of feeding best suited for them and their infant. Breastfeeding, like bottle feeding, may be difficult but can be facilitated if the mother is supported in this decision. If the cleft isn't severe, breastfeeding may be easier than other feeding techniques because the human nipple conforms to the shape of the infant's mouth. Feedings are usually given in the upright position to prevent formula from coming through the nose. Various special nipples have been developed for infants with cleft lip or palate. A regular nursery nipple is not effective.

A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action? A. Push the call light and ask for help. B. Hold the child down to prevent injury. C. Loosen any restrictive clothing. D. Force the jaw open to maintain an open airway.

C. Loosen any restrictive clothing. The primary nursing goal during a seizure is to protect the client from physical injury and maintain a patent airway. Loosening clothing, especially around the neck, will allow free movement and aid in keeping the airway open.

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client? A. Provide emotional support. B. Provide nutritional support. C. Provide pain control. D. Provide education about end-of-life.

C. Provide pain control.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks? A. The RN must directly supervise all delegated tasks. B. After a task is delegated, it's no longer the RN's responsibility. C. The RN delegates a task based on the UAP's skill set. D. Follow-up with a delegated task is only necessary if the UAP is untrustworthy.

C. The RN delegates a task based on the UAP's skill set.

A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request? A. Assess the child's pain by asking the child to rate the pain on a 1 to 10 scale. B. Prepare to administer the ordered pain medication. C. Use the Faces Pain Scale to assess the child's degree of pain. D. Document the report of pain, and note the time of the last pain medication.

C. Use the Faces Pain Scale to assess the child's degree of pain.

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN? A. passing dinner trays B. emptying a Foley catheter bag C. administering daily am medications D. suctioning a client who is 1-day postoperative following a tracheostomy

C. administering daily am medications

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse? A. total weight gain of 30 lb (13.6 kg) B. maternal age of 32 years C. blood pressure of 146/90 mm Hg D. treatment for syphilis at 15 weeks' gestation

C. blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? A. obtain a throat culture B. place the child in a side-lying position C. have emergency airway equipment readily available D. obtain blood cultures

C. have emergency airway equipment readily available Emergency airway equipment and humidified oxygen should be readily available. The nurse should not attempt to visualize the epiglottis, use tongue blades or throat culture swabs, which can cause the epiglottis to spasm, and totally occlude the airway. Throat inspection should only be attempted when immediate intubation or tracheostomy can be performed in the event of further or complete obstruction.

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention? A. chest tube insertion B. escharotomy C. intubation D. needle thoracentesis

C. intubation Intubation is performed to maintain a patent airway. Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracentesis are performed to relieve a pneumothorax.

A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to: A. check the fetal heart rate B. check the maternal blood pressure C. maintain an open airway D. administer oxygen to the mother by face mask

C. maintain an open airway The initial nursing action when a client progresses to an eclamptic state (has a seizure) is to maintain an open airway.

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis? A. onset and character of fever B. degree and extent of nuchal rigidity C. signs of increased intracranial pressure (ICP) D. occurrence of urinary and fecal incontinence

C. signs of increased intracranial pressure (ICP) Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessing for signs of increasing ICP should be the highest priority due to the life-threatening implications.

An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? A. A child with a bleeding laceration B. A 54-year-old woman with a fractured wrist C. A 67-year-old woman with first-degree burns on her hands and arms D. A 45-year-old man with chest pain, shortness of breath, and diaphoresis

D. A 45-year-old man with chest pain, shortness of breath, and diaphoresis Airway is always a priority, and a client who complains of chest pain is assigned an immediate care priority rating

The nurse is assigned to care for four clients. Which client should the nurse assess first? A. A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/min B. A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on hospice care C. A client admitted one day ago with thrombophlebitis who is receiving IV heparin D. A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

D. A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem The client with atrial fibrillation has the greatest potential to become unstable, and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the client admitted two days ago with heart failure. The client with end-stage right-sided heart failure, who is identified as a hospice client is of lowest priority.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client? A. Perform gastric lavage. B. Obtain blood work. C. Administer I.V. fluid. D. Administer acetylcysteine.

D. Administer acetylcysteine. If the client is seen within 1 hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? A. Wash the circumcised penis with warm water. B. Change the diaper as needed. C. Keep a bandage on the site for 24 to 48 hours. D. Apply petroleum jelly to the site for 24 to 48 hours.

D. Apply petroleum jelly to the site for 24 to 48 hours. Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper.

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis? A. Lay the client supine. B. Avoid packing the nostrils. C. Apply a warm cloth to the bridge of the nose. D. Apply pressure to the nose.

D. Apply pressure to the nose.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action? A. Vigorously massage the fundus. B. Call the health care provider immediately. C. Have the charge nurse review the assessment. D. Ask the client when she last changed her perineal pad.

D. Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, and the perineal pad may have been in place all night. In addition, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended if heavy bleeding or hemorrhage is present.

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action? A. Ask how long the parent will be gone. B. Tell the 2-year-old child everything will be all right. C. Tell the 2-year-old child the nurse will stay. D. Ask the parent if there's anyone else who can meet the older child.

D. Ask the parent if there's anyone else who can meet the older child.

A client is brought to the emergency department after a house fire. What is the priorityassessment by the nurse? A. Assess the depth and total surface area of burns. B. Collect a full set of vital signs and spheres of orientation. C. Assess the level of pain and medication allergies. D. Assess oxygen saturation and the client's ability to speak.

D. Assess oxygen saturation and the client's ability to speak. nurse's priority is to make sure the airway is open and that the client is breathing, which would be best accomplished by seeing if the client can speak and what the oxygen saturation is. Vital signs, degree of burns, and the client's pain can all be assessed once the nurse establishes that the client has a patent airway.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action? A. Call for help B. Obtain vital signs C. Ask the client to "lift up" D. Assess the groin site

D. Assess the groin site

The nurse is preparing to assess a child with a possible cardiac anomaly. What is the priorityassessment for this nurse? A. Skin turgor B. Temperature C. Pupil size and reaction to light D. Blood pressure in all four extremities

D. Blood pressure in all four extremities

A 72-year-old client with cirrhosis is admitted to the hospital in a hepatic coma. What is the nurse's most important intervention? A. Perform a neurological check, cardiovascular check, and gastrointestinal assessment. B. Complete the client admission. C. Orient the client to the environment. D. Check airway, breathing, and circulation.

D. Check airway, breathing, and circulation. ABC baby, oh gawd yea

The nurse is caring for a client with type 1 diabetes mellitus. At 0300, the nurse finds the client disoriented to time and place, diaphoretic, and reports palpitations. What is the nurse's priorityintervention? A. Give 10 to15 g of carbohydrate orally. B. Call the healthcare provider for additional insulin order. C. Administer 1 mg of glucagon subcutaneously. D. Check blood glucose level.

D. Check blood glucose level.

A client who is experiencing thoughts of self-harm is brought to the crisis response center by family members. Which action is most important for the nurse to implement? A. Establishing trust with client. B. Assessing for auditory hallucinations. C. Teaching relaxation techniques. D. Implementing suicide precautions.

D. Implementing suicide precautions.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? A. Tell her that her milk is starting to come in because she's in labor. B. Complete a thorough breast examination and document the results in the chart. C. Perform a culture on the discharge, and inform the client that she might have mastitis. D. Inform the client that the discharge is colostrum, and a normal finding.

D. Inform the client that the discharge is colostrum, and a normal finding.

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention? A. Leave the client and call the provider. B. Put the client in a semi-Fowler's position. C. Ask the client to push with the next contraction. D. Leave the fingers in place and press the nurse call light.

D. Leave the fingers in place and press the nurse call light. When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth.

An adolescent client is admitted for treatment of anorexia nervosa with a body mass index (BMI) of 13. What is the nurse's priority in planning the care? A. Encourage the client to perform muscle-building exercises. B. Keep the client on bed rest until the goal weight is achieved. C. Meet daily with the client to discuss manipulation and countertransference. D. Monitor the client's urine output and vital signs.

D. Monitor the client's urine output and vital signs. A BMI of 13 is severely underweight and poses a risk to the client's physical health, including potential cardiac dysrhythmia, hypotension, or kidney failure.

A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client? A. Promote sleep and rest B. Encourage therapeutic communications C. Maintain standard precautions D. Pain management

D. Pain management

Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg? A. Appropriate dose of aspirin and rest B. Immobilization of the leg and a dose of ibuprofen C. Heating pad and administration of factor VIII concentrate D. Pressure on the site and administration of the required clotting factor

D. Pressure on the site and administration of the required clotting factor With any bleeding injury in a client with hemophilia, the first line of treatment is always to replace the clotting factor. Pressure is applied along with cool compresses, and the extremity is immobilized. Aspirin is not used because of its anticoagulant properties and the risk of Reye's syndrome in children. Immobilizing the leg and giving ibuprofen would be done after applying pressure and administering the necessary clotting factor. Heat is not used because it increases bleeding.

A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? A. Assess fetal heart tones via external monitor. B. Reassure the client that she'll get pregnant again soon. C. Avoid talking about the baby. D. Provide privacy and emotional support.

D. Provide privacy and emotional support. Providing privacy and support is an appropriate therapeutic intervention for the client and family to grieve their loss. Fetal heart tones are rarely assessed in a client with an anencephalic fetus. Most fetuses will not survive due to a lack of cerebral function. Reassuring the client that she will get pregnant again dismisses how she feels about her current loss, and also provides false reassurance.

A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? A. the RN need not to carry out further assessment because the LPN is very experienced and trustworthy B. the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively C. the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic D. the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

D. the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

digoxin dose furosemide dose morphine dose

dig: 0.6-2 furosemide: 20-80 mg po morphine: 2-4 mg IVP 5 min

On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated? A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature, oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulating.

A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema.

A nurse is caring for a child with a spinal cord lesion at the level of the seventh cervical vertebrae. The child becomes flushed, diaphoretic, and hypertensive and reports a headache and blurred vision. What is the priority nursing action? A. Assess the bladder for distension and slowly drain if distended. B. Administer antihypertensive and pain medication. C. Remove external stimulation and tight clothing. D. Administer a stool softener and perform manual anal stimulation.

A. Assess the bladder for distension and slowly drain if distended. This child is exhibiting signs and symptoms of autonomic stimulation. Although it could be caused by fecal impaction, the most common cause is a distended bladder. All other interventions are correct, but the nurse's priority must be to remove the stimulus for the condition.

An adolescent female client reports a low-grade fever; lower abdominal pain; and frequent, painful urination. What is the nurse's priority action? A. Assess the client for additional signs and symptoms of pelvic inflammatory disease (PID). B. Refer the client to be assessed for HIV. C. Educate the client about the prevention of sexually transmitted infections (STIs). D. Inspect the client's vulva for the presence of chancres.

A. Assess the client for additional signs and symptoms of pelvic inflammatory disease (PID).

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's

A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI)

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

A. Cleaning a client's dentures B. Ambulating a postoperative client C. Taking 4:00 p.m. vital signs on clients E. Assisting a client with a urinary drainage catheter into a chair Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the AP; therefore, these options are incorrect.

The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. A. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable B. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias C. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma D. Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr E. Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92% F. Client with white blood cell count of 2200 mm3 (2.2 × 109/L), temperature of 102º F (38.9º C), and blood pressure of 90/40 mm Hg

A. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable B. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias C. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma

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

A. Collecting a urine specimen from a client B. Obtaining frequent oral temperatures on a client C. Accompanying a client being discharged to his or her transportation to home

The nurse is developing a client care assignment for a group of assistive personnel (APs). What is the nurse's first step in planning and assigning clients? A. Determine what skills can be delegated. B. Determine the years of experience of each AP. C. Determine how much supervision is required for each client assigned. D. Determine how many clients the agency allows to be delegated to each AP.

A. Determine what skills can be delegated.

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

A. Empty a client's urinary catheter bag. Only an RN can teach, evaluate, and instruct.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention? A. Maintain the client on respiratory isolation B. Prepare the client to be discharged on bed rest C. Administer the tuberculin test ordered by the health care provider D. Administer the isoniazid ordered by the health care provider immediately before discharge

A. Maintain the client on respiratory isolation

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

A. Orient the client to the hospital surroundings. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse.

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A. Perform postural drainage and chest physiotherapy every 4 hours. B. Allow the patient to decide whether she needs aerosolized medications. C. Place the patient in a private room to decrease the risk of further infection. D. Plan activities to allow at least 8 hours of uninterrupted sleep.

A. Perform postural drainage and chest physiotherapy every 4 hours.

As the registered nurse, which tasks below should you NOT delegate to the LPN? A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin E. Auscultating lung and bowel sounds F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain H. Providing wound care to a stage 3 pressure injury

A. Performing an assessment on a new admission C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain

The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? A. Remove the IV catheter. B. Apply a warm compress. C. Check for a blood return. D. Measure the area of infiltration.

A. Remove the IV catheter. Blanching, coolness, and edema of the IV site all are classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the nurse should remove the IV catheter to prevent any further damage. Warm compresses may be applied to the infiltrated area only after the IV catheter is removed and only if the infiltrated solution is not damaging to the surrounding tissues. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Measuring the area of infiltration would be done after the IV catheter has been removed to assess for any further tissue damage.

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

A. The acuity level of the clients E. Client needs and workers' needs and abilities These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care.

When planning care, which client should the nurse assess first? A. The client with a chest tube for a pneumothorax B. The client who had a cholecystectomy 2 days earlier C. The client who is receiving total parenteral nutrition and lipids D. The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)

A. The client with a chest tube for a pneumothorax The client with a chest tube for a pneumothorax should be assessed first, based on the airway compromise. This client could very well have problems with breathing.

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include? A. Use a caring approach to maintain close observation of the client B. Develop a strong and healthy relationship with the client C. Obtain an order for an antianxiety medication to keep the client calm D. Encourage the client to avoid over-stimulating group activities

A. Use a caring approach to maintain close observation of the client Close observation, using a caring and therapeutic approach, is essential in order to decide the level of suicide precautions needed. Merely developing a strong relationship with the client isn't addressing the client's potential for self harm.

A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. D. Use a rectal thermometer to obtain a more accurate body temperature. E. Be sure the patient's footwear has a firm sole when the patient ambulates.

A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. E. Be sure the patient's footwear has a firm sole when the patient ambulates.

A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? A. examine and treat the wound sites B. obtain and record a detailed history C. encourage and assist the client to ventilate feelings D. administer an anti-anxiety agent

A. examine and treat the wound sites

A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first: A. inspect the client for injuries resulting from the incident and initiate appropriate treatment B. document the behavior leading to seclusion C. document the time and the client is placed in seclusion D. make sure that there is a written order by the physician allowing for the seclusion

A. inspect the client for injuries resulting from the incident and initiate appropriate treatment

A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: A. obtain vital signs B. ask the client about the precipitating events C. complete an abdominal physical assessment D. insert a nasogastric (NG) tube and Hematest the emesis

A. obtain vital signs The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment.

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? A. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment B. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected C. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day D. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

B. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP.

Which patients below are best assigned to the LPN? A. A 30-year-old male patient with active GI bleeding that requires multiple blood transfusions. B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. D. A 55-year-old male patient who reports chest pain and has ST segment elevation on his EKG.

B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet.

The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? A. Put on gloves. B. Evaluate the client's visual acuity. C. Place the client in a supine position. D. Place a strip of pH paper in the lower sac of the client's affected eye.

B. Evaluate the client's visual acuity. Before performing an ocular irrigation on a client who had an episode of splashing in the eye, the nurse must first evaluate the client's visual acuity. All of the other options can then be performed.

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

B. Move beds away from windows. C. Close window shades and curtains. D. Place blankets over clients who are confined to bed. protecting clients from flying debris or glass nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

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

B. Providing distraction for the client by engaging the client in a board game

When delegating you know that as an RN you must follow the 5 Rights of Delegation to make sure you are delegating properly. Select all the 5 Rights of Delegation: A. Right Credentials B. Right Direction/Communication C. Right Supervision D. Right Experience E. Right Task F. Right Person G. Right Patient H. Right Circumstance I. Right Time J. Right Order

B. Right Direction/Communication C. Right Supervision E. Right Task F. Right Person H. Right Circumstance

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

B. Stop administering the enemas. If administering enemas until clear is prescribed on the morning of the test, enemas should be administered no more than 3 times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances.

The nurse has received her client assignment for the day. Which client should the nurse care for first? A. The 43-year-old client admitted for observation who has absence of bowel sounds B. The 53-year-old client with heart failure who has gained 4 lb (1.8 kg) since yesterday and is short of breath C. The 49-year-old client who is scheduled for surgery within the next 2 hours and will undergo a hysterectomy D. The 12-hour postoperative client who has undergone pneumonectomy and is completing a blood transfusion

B. The 53-year-old client with heart failure who has gained 4 lb (1.8 kg) since yesterday and is short of breath

The nurse should instruct the assistive personnel (AP) to avoid the use of a straight razor for which client? A. The postoperative client B. The client taking warfarin C. The client with an infection D. The client taking acetaminophen

B. The client taking warfarin

The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? A. The client who lacks knowledge regarding postoperative home care B. The client with problems clearing the airway related to abdominal incision pain C. The client with tissue perfusion alterations related to postoperative venous stasis D. The client who is at risk for infection related to a history of smoking for 20 years

B. The client with problems clearing the airway related to abdominal incision pain

Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. A. Assessment B. Urinary catheterization C. Endotracheal suctioning D. Intramuscular medication administration E. Subcutaneous medication administration F. Intravenous push medication administration

B. Urinary catheterization C. Endotracheal suctioning D. Intramuscular medication administration E. Subcutaneous medication administration

A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? A. a 2-day postoperative client who had a below-the-knee amputation B. a client on a 24-hour urine collection who is on strict bedrest C. a client scheduled to be discharged after coronary artery bypass surgery D. a client scheduled for a cardiac catheterization

B. a client on a 24-hour urine collection who is on strict bedrest

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? A. an alert victim who has numerous bruises on the arms and legs B. a victim with a partial amputation of a leg who is bleeding profusely C. a hysterical victim who received a head injury D. a victim who sustained multiple serious injuries and is deceased

B. a victim with a partial amputation of a leg who is bleeding profusely The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent

A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? A. continually reassure and coach the client B. administer the prescribed oxygen throughout labor C. maintain strict asepsis throughout the labor process D. increase the intravenous (IV) fluids if the client complains of feeling thirsty

B. administer the prescribed oxygen throughout labor During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and is at high risk for sickle cell crisis. An intervention to prevent sickle cell crisis during labor includes administering oxygen. Options A and C are appropriate interventions during labor but are not specific to sickle cell anemia. Intravenous fluids may need to be increased, but a physician's order is needed to do so.

The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to: A. speak briefly and directly. B. avoid blaming or preaching to the client. C. confront feelings and examples of perfectionism. D. determine if nonverbal communication will be more effective.

B. avoid blaming or preaching to the client. Blaming or preaching to the client causes negativity and prevents the client from hearing what the nurse has to say. Speaking briefly to the client may not allow time for adequate communication.

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? A. repositions side to side every 2 hours B. elevates the head of the bed 60 degrees C. auscultates the lung field every 4 hours D. encourages deep breathing exercises every 2 hours

B. elevates the head of the bed 60 degrees The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? A. age B. hypertension C. hyperlipidemia D. glucose intolerance

B. hypertension A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range

What is the most important action to take for a child with ineffective airway clearance? A. reducing the child's anxiety B. suctioning the child's secretions C. providing adequate oral fluids D. administering medications as ordered

B. suctioning the child's secretions The most important goal is to maintain a patent airway. The child with ineffective airway clearance has secretions that can obstruct the airway. Reducing anxiety and administering medications will be necessary after the airway is secure. The child should not be allowed to eat or drink anything to prevent the risk of aspiration.

A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: A. interaction with peers B. the presence of suicidal thoughts C. the amount of food intake for the past 24 hours D. information regarding the past medication regimen

B. the presence of suicidal thoughts

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from bronchoscopy and biopsy. C. A 72-year old who needs teaching about the use of incentive spirometry. D. A 69-year old with COPD who is ventilator dependent.

C. A 72-year old who needs teaching about the use of incentive spirometry.

You're making the patient assignments for the next shift. On your unit there are three LPNs, two RNs, and two nursing assistants. Which patients will you assign to the LPNs? Select all that apply: A. 68 year-old male patient who is expected to be discharged home with IV antibiotic therapy. B. A 25 year-old female patient newly admitted with diabetic ketoacidosis. C. A 75 year-old male patient with dementia who has an ileostomy and scheduled tube feedings. D. A 65 year-old female patient who has an order to remove the Foley catheter.

C. A 75 year-old male patient with dementia who has an ileostomy and scheduled tube feedings. D. A 65 year-old female patient who has an order to remove the Foley catheter.

The nurse has received her client assignment for the day. Which client should the nurse check first? A. A client experiencing severe pain B. A client who is hearing voices in his or her head C. A client who has just returned from surgery D. A client who is in 4-point leather restraints

C. A client who has just returned from surgery Priority clients are those who have a problem or potential problem with airway, breathing, or circulation. A client who has just returned from surgery could experience problems with all 3. The client experiencing severe pain would be attended to next. Then the nurse would care for the client who is hearing voices in his head, followed by the client who is in 4-point leather restraints.

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

C. A client who requires urine specimen collections

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

C. A postoperative client is discharged home 1 day earlier than expected. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path.

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

C. Administration of a new oral medication to a client with Alzheimer's disease

Select all the task you could delegate to a nursing assistant as the RN: A. Wound dressing change B. IV flush C. Collecting vital signs D. Weighing a patient E. Mouth care F. Suctioning a patient G. Applying oxygen to a patient H. Connecting a patient to their IV fluids I. Assisting a patient with a bath J. Applying denture paste to dentures

C. Collecting vital signs D. Weighing a patient E. Mouth care I. Assisting a patient with a bath J. Applying denture paste to dentures

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the assistive personnel (AP)? Select all that apply. A. Inspecting skin surfaces B. Observing the client's behavior C. Measuring the client's height and weight D. Assessing the client's general appearance E. Monitoring oral intake and urinary output

C. Measuring the client's height and weight E. Monitoring oral intake and urinary output

A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? A. Monitor temperature. B. Monitor urine output. C. Monitor respiratory status. D. Encourage increased fluids.

C. Monitor respiratory status.

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? A. Prepare the child for tracheotomy. B. Prepare to administer epinephrine. C. Prepare the child for a chest radiograph. D. Assist the primary health care provider with intubation.

C. Prepare the child for a chest radiograph. You need to make sure the child has epiglottis and diagnosis with an x ray first. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient. B. Teach the patient how to set up the BiPAP machine before sleeping. C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness.

C. Remind the patient to sleep on his side instead of his back.

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

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

During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first? A. The 80-year-old client with metastatic cancer to the brain who is confused and on 1-to-1 observation with a sitter in the room B. The 55-year-old client with breast cancer who is scheduled for a computed tomographic (CT) scan of the brain at 0900 to rule out metastasis C. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon D. The 70-year-old client who was admitted at 0500 with the medical diagnosis of pneumonia and a temperature of 102.6º F (39.2º C). This client received acetaminophen at 0600 and now has a temperature of 100.0º F (37.8º C)

C. The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon The nurse would plan to first see the client who is receiving chemotherapy for the first time. This is the highest priority because of the potential side and adverse effects of the medication and the fact that this is the first dose the client has received.

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

C. The LPN places the client's knee in a slightly externally rotated position. the leg should be kept in a neutral position and not rotated either internally or externally.

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

C. The client receiving continuous oxygen at 2 L/min D. The client recovering from Guillain-Barré syndrome F. The client on isolation for methicillin-resistant Staphylococcus aureus The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).

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

C. The client with thrombocytopenia related to chemotherapy

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

C. The nurse who never had chickenpox E. The nurse who never received the varicella-zoster vaccine

A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? A. ultrasound B. colonoscopy C. barium enema D. computed tomography

C. barium enema When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priorityattention? A. loss of appetite B. explosive diarrhea C. projectile vomiting D. constipation

C. projectile vomiting The obstruction doesn't allow food to pass through the pylorus to the duodenum. When the stomach becomes full, the infant forcefully vomits for pressure relief. This can result in dehydration, electrolyte imbalances, and nutritional deficiency. Chronic hunger is commonly seen. Because food doesn't pass the stomach, neither diarrhea nor constipation will occur.

A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: A. lung sounds B. vital signs C. the chest tube connections D. the amount of drainage

C. the chest tube connections Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

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

D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? A. A primigravida client in the active stage of labor B .A multigravida client who was admitted for induction of labor C. A client who is not contracting but has suspected premature rupture of the membranes D. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

D. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor Magnesium sulfate is a central nervous system depressant, and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/min), severe hypotension, and absent deep tendon reflexes. This client should be seen before the clients in all other options because their conditions are stable.

Which client would be considered to be at the highest risk for respiratory failure? A. A client with breast cancer B. A client with cervical sprains C. A client with a fractured hip D. A client with Guillain-Barré syndrome

D. A client with Guillain-Barré syndrome Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

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

D. A client with a spinal cord injury requiring urinary catheterization every 6 hours

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

D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

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

D. A client with asthma who requested a breathing treatment during the previous shift Airway is always the highest priority. This could indicate that the client was experiencing difficulty breathing.

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

D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce don't just assume bc what he ate could be heart burn, he could be having a MI or something else Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.

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

D. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion The clients described in options 1, 2, and 3 can appropriately be cared for by the AP.

The nurse has received her client assignment for the day. Which client should the nurse care for first? A. A client requiring a preoperative intravenous antibiotic B. A client with emphysema who has shortness of breath after just ambulating C. A client with serous drainage on an incisional spinal wound post laminectomy D. A client with postoperative pain reported at 7 out of 10, with 10 being the worst

D. A client with postoperative pain reported at 7 out of 10, with 10 being the worst In this situation, the client with the pain reported at 7 out of 10 should be cared for first. The pain will intensify and be harder to manage if treatment is delayed. Caring for the client in pain may delay administration of the preoperative antibiotic but does not jeopardize safe and effective care. Shortness of breath is expected in a client with emphysema after ambulation and therefore is not the priority. Serous drainage is expected from a surgical incision and does not indicate an emergency.

An RN has a critical patient that needs constant monitoring. However, the RN also has other patients in need of care. Which tasks below could the RN delegate to the LPN to help continue the process of patient care? A. Admitting and assessing the new admission B. Completing the discharge teaching to a patient going home C. Updating and evaluating the patient's plan of care D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen G. Flushing a central line with normal saline

D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen

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

D. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients.

The nurse is planning client assignments for the day. Which clients can be safely assigned to assistive personnel (APs)? Select all that apply. A. Client who is receiving chemotherapy and is in isolation B. Client with anemia who is receiving a second unit of blood and needs assessment of vital signs C. Client newly diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy D. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing E. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding F. Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment

D. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing E. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding

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

D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

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

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

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

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

The nurse has received the client assignment for the day. Which client should the nurse care for first? A. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition B. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area C. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site D. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

D. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

The nurse determines that which client has the highest priority needs? A. The client who has a rectal temperature of 99.8º F B. The client who has a blood pressure of 110/70 mm Hg C. The client who has an oxygen saturation percentage of 95% D. The client who has an irregular apical pulse of 120 beats per minute

D. The client who has an irregular apical pulse of 120 beats per minute

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? A. The 11-year-old with burns to 10% of both legs B. The sobbing 10-year-old with an obvious fracture of the forearm C. The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute D. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

D. The confused 12-year-old with bright red blood pulsing from an open fracture of the femur Triage systems identify who should be treated first. Rankings are based on immediacy of needs, including immediate threats to life such as airway compromise or hemorrhagic shock. The 12-year-old who is demonstrating confusion is becoming hypoxic because of profound blood loss. The other victims are more stable and could wait.

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4ºF (38.6ºC)

D. Tympanic temperature of 101.4ºF (38.6ºC) Infections are always a threat to the patient receiving mechanical ventilation

A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? A. providing range-of-motion exercises to the wrists B. removing the restraints periodically per agency guidelines C. applying lotion to the skin under the restraints D. assessing color, sensation, and pulses distal to the restraint

D. assessing color, sensation, and pulses distal to the restraint

A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: A. the comfort level B. activity tolerance C. the level of consciousness D. the hydration and nutrition status

D. the hydration and nutrition status Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished.