*HURST REVIEW Qbank/Customize Quiz - Management of care

A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? Select all that apply 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. 2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice. An experienced registered nurse or primary healthcare provider must be specifically trained to perform this procedure. 3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of fetal well being and not within the LPN scope of practice.

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? Select all that apply 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.

4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.

What clients could safely be delegated to the LPN/LVN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1, 2, 5 & 6. Correct: These clients are appropriate and stable enough for the LPN/LVN's scope of practice. While an LPN/LVN cannot be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/LVN could even delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need a respiratory assessment by the RN at some point, but the LPN/LVN is definitely qualified to administer aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no injuries serious enough for a full admission. PNs can insert and monitor NG tubes. 3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about self care at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an LPN/LVN. This option does not indicate that any teaching had been presented, so the client is not an appropriate assignment for the LPN/LVN. 4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need for close monitoring and frequent assessment of the respiratory system, requiring an RN.

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

1. Correct: A comment should be made about keeping the client covered. This instruction is the first action after covering the client. 2. Incorrect: The nurse should talk with the UAP but the discussion should focus specifically about providing privacy for clients. 3. Incorrect: The nurse may want to provide teaching, but this is not first action. Teaching would require allowing enough time to give instructions and then arranging time for return demonstration. 4. Incorrect: The UAP should be allowed to finish the bath. Additional assistance is not needed.

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

1. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This referral would be appropriate. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Aplastic anemia is a rare but serious condition. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated.

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

1. Correct: Clients often go home quickly and do not completely understand discharge instructions. The first priority would be for colostomy care, which can be provided by home health. 2. Incorrect: Meals on Wheels will be important later during rehabilitation but is not the priority. 3. Incorrect: Hospice care is premature. The question does not reveal if surgery was successful or not to remove the colon cancer. 4. Incorrect: A dietary consult may be necessary later, but is not the priority at present.

After reviewing the client assignments, the LPN/LVN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/LVN how the client assignment should be adjusted. 2. Assign one of the LPN/LVN's clients to another nurse. 3. Encourage the LPN/LVN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Correct: Explore her concerns; this is most therapeutic and helpful response. Finding out what are LPN/LVN's concerns first will help the RN address the LPN/LVN's request and build trust in the healthcare team relationship. 2. Incorrect: This statement does not help the RN understand the LPN/LVN's concern about the assignment, an negates the confidence in the LPN/LVN's abilities and skills. 3. Incorrect: This answer does not acknowledge the LPN/VN's concern. 4. Incorrect: This action will not help address the LPN/LVN's immediate concern with the assignment and makes resolution of the issue much more complicated than it should be.

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

1. Correct: Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented. 2. Incorrect: Beneficence refers to doing good. This may include compassion and kindness. 3. Incorrect: Justice refers to equitable distribution of resources. Triage in the ED is one action that illustrates justice. 4. Incorrect: Fidelity refers to truth-telling. If the client were to ask if a medication error was made, the nurse would answer yes to the question as a way of demonstrating fidelity.

After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.

1. Correct: The client diagnosed with an ischemic stroke needs to be assessed first to be evaluated for signs of increased intracranial pressure (ICP). A neurological assessment should be initiated. Increased restlessness is an early sign of increased ICP. 2. Incorrect: Client safety should be evaluated. The client does require assistance with ambulating. But the client with potential increased ICP requires an immediate neurological assessment. 3. Incorrect: A client with a halo traction may require assistance to transfer to the chair. The nurse identifies that a neurological assessment on another client has priority. 4. Incorrect: The client with the traumatic head injury cannot recall portions of the accident, but is not presenting with any life-threatening symptoms.

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the plan will be implemented and those not following the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

1. Correct: The key word in the stem is first. So yes, get everyone together and discuss the problem and find areas of compromise where possible. 2. Incorrect: Too authoritative. This is good staff that has worked together on the unit for a long time. We want them to be happy and get the work done. Again, the key word in the stem is first. 3. Incorrect: No, this is a manager's issue resulting from a new system. This may need to be done but is not the first action. 4. Incorrect: Explaining the rationale to one group does not promote teamwork. It is better to plan a unit staff meeting and not a meeting for only the UAPs.

Which task would be appropriate for the nurse to assign to an LPN/LVN? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

1. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/LVN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/LVN. Therefore, the RN must perform this task and cannot delegate this to the LPN/VN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Teaching insulin self administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. This should not be delegated to the LPN/LVN.

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the gynecological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. Correct: This client needs a private room so she can feel free to grieve and have family members stay with her for support. She should be transferred to a gynecological unit so the sights and sounds of the maternity unit do not contribute to her pain. 2. Incorrect: Difficult for mother with stillborn to be on postpartum unit with mothers and their babies. The mother should not be surrounded by these reminders. 3. Incorrect: She does not need to be rushed out of the hospital. She needs to have time with her stillborn and also still needs to be assessed for postpartum complications. Remember that she is going through all of these postpartum stages of normal delivery and requires observations. 4. Incorrect: I know we say like illnesses go together but not here. This client needs privacy and time with her family.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, postpartum infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical. 2. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This group of clients needs specialized care. 4. Incorrect: No, the monitoring is too specific for the med-surg nurse.

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the nurse manager is not caught in the middle. They will be able to come up with solutions together or the manager can mediate. 2. Incorrect: It is ok to clarify that the nurse followed hospital procedure. However, the nurse is sing the nontherapeutic communication technique of blocking. The family member may still believe that there is another procedure that could have been initiated. 3. Incorrect: You may want to do this as well, but it will not address the conflict. The conflict is that the family member disagrees with the nurse's procedure for dressing change. 4. Incorrect: The nurse manager must try to resolve the conflict between the family member and the nurse first. If the conflict cannot be resolved the nurse manager would notify the person that is next in the chain of command.

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

1., & 4. Correct: QD is listed on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) official "do not use" list of abbreviations. This should be prescribed as "daily" instead of "QD". The abbreviation T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week". 2. Incorrect: This is a correct action, for a client with Addison's disease, and it is written properly. 3. Incorrect: The primary healthcare provider may suggest a MRI scan of the pituitary gland if testing indicates the client might have secondary adrenal insufficiency. This is an approved abbreviation. 5. Incorrect: This is written correctly and may be given to women to treat androgen deficiency in cases such as this client with Addison's disease.

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? Select all that apply 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5 mg PO daily 5. Dexlansoprazole 30 mg PO daily

1., 2., 3., & 4. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. So what is wrong with option #1? Well, do you see the q.d.? This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. Now, in Option #2, we see a dangerous prescription. There is a trailing zero after the prescribed dose. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Administering 3 g/hr IV of morphine would be extremely dangerous. In option #4, we see that the leading zero is missing from the prescription. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. 5. Incorrect: This prescription is written correctly.

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1., 2., 3., & 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 5. Incorrect. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court.

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? Select all that apply 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

1., 3. & 5. Correct: Client advocacy has been described in many different ways and involves many things such as assistance in gaining needed healthcare, assuring quality of care, protection of client's rights, and simply serving as a mediator between the client and the healthcare system as a whole. Client advocacy involves regular communication in which the nurse explains what is being done or likely to happen, reasons for tests or procedures, and simplifying medical terminology into words that can be easily understood. Emotional support is also an aspect of client advocacy that the nurse should employ. The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and by fostering a sense of security. 2. Incorrect: This question addressing client advocacy is not related to client compliance. Client compliance may improve if the nurse served as an appropriate client advocate. However, promotion of compliance is not a basic part of advocacy. 4. Incorrect: This question addressing client advocacy is not related to client's healthcare treatment wishes. This would be related to the client's advance directive.

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client reminisce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not delegate routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

1., 4., & 5. Correct: Administering enemas and antibiotics to a client is within the scope of practice of the LPN. Nausea and vomiting are common side effects after a client receives chemotherapy. The LPN can administer antiemetics and monitor fluid status. It is within the scope of practice for the LPN to perform sterile dressing changes. 2. Incorrect: This client is a new admit who is in DKA and would be unstable. 3. Incorrect: This client will require frequent assessments and monitoring for postop complications.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1., 4., & 5. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. So, the UAP can assist a client to brush and floss teeth. UAPs can assist with elimination and are taught how to measure output. This would be an acceptable task to assign to the UAP. Gathering needed equipment and supplies is within the scope of duties for the UAP. 2. Incorrect: It is out of the UAP's scope of practice to administer medication. This includes medication enemas. Only a plain enema or soap enema can be given by the UAP. 3. Incorrect: The nurse is responsible for evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 6. Incorrect: The nurse is responsible for monitoring a client. This would be out of the UAP's scope of practice. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data.

The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? Select all that apply 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus

1., 4., 5., & 6. Correct: Federal and state laws require that certain individuals, particularly those who work in health care with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. This includes physical, mental, and financial abuse. Gunshots and knife injuries are reportable to law enforcement. Certain communicable diseases such as gonorrhea and West Nile virus are reportable to the CDC. 2. Incorrect: Suspected negligence of a colleague is not in the realm of mandatory reporting to authorities, but the nurse should discuss with the supervisor. 3. Incorrect: A spouse is not considered a vulnerable person so it is not required by law to report. You should encourage the spouse to report the abuse but you, as the nurse, are not bound by law to do so.

A charge nurse is teaching a new nurse on the labor and delivery floor the proper positioning of a client following an epidural. The charge nurse knows the teaching was successful when the new nurse places the client in which position? 1. Lithotomy 2. Left-lateral 3. Semi-Fowler's 4. Right-lateral

2. CORRECT: The left-lateral position is most appropriate following epidural anesthesia. In this position, the placenta is well perfused and the client is less likely to experience side effects from anesthesia, such as hypotension. 1. INCORRECT: The lithotomy position is supine with legs separated, knees flexed and elevated with feet supported in stirrups. Such a position is appropriate for gynecologic exams, but would place too much pressure on the vena cava at this time. 3. INCORRECT: In this position, the client is supine with the head of the bed elevated between 30 and 90 degrees. This is a good position for those with breathing difficulties; however, following an epidural, elevating the head may drop the blood pressure, while leaving the client supine and putting pressure on the vena cava. 4. INCORRECT: The right-lateral position is on the right side, with left leg flexed toward the head, and is useful to avoid hypotension. But this is not the best position following an epidural for improving uteroplacental perfusion.

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing it into 3 ounces of applesauce, the new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2. Correct. Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1. Incorrect. There is nothing in the stem about a problem with the medication dose or route. The drug reference book does not provide guidelines for meeting developmental needs when administering the medication. This is something that the nurse must look up if uncertain about developmental tasks. 3. Incorrect. There is nothing in the stem about a problem with the medication dose or route. Once the medication has been mixed in applesauce, the supervising nurse would not be able to compare the dose to the prescribed amount. Therefore, this would not be an appropriate action. It would not address the developmental task that is the underlying issue here. 4. Incorrect. This is an appropriate action. However, it is not the priority. The new nurse should be competent in medication administration but is needing guidance with the developmental considerations related to medication to a nine month old.

Several clients have reported to the charge nurse that they are not receiving pain relief when a certain RN administers their pain medication. The charge nurse has noticed that the RN has been looking unkempt in appearance and seems to be in a daze much of the time. What is the most appropriate action for the charge nurse to take? 1. Lessen the nurse's client assignment to see if things improve. 2. Discuss the concerns directly with the nurse. 3. Give the nurse a 6 month period to be observed. 4. Avoid confronting the nurse so that the client's care will not be jeopardized.

2. Correct: This may be a situation in which the charge nurse must address the issue of an impaired nurse. All nurses should be aware of the signs and symptoms of substance abuse. The best way for the charge nurse to deal with these suspicions initially is to directly discuss the concerns with the nurse. Intervention may be needed immediately to protect the safety of the clients. If deemed appropriate, the charge nurse may encourage the nurse to seek help independently. 1. Incorrect: This action will not do anything to help an impaired nurse. In fact, this could potentially put the few clients being cared for by this nurse at risk of harmful actions, and it could create an unsafe workload on the other nurses who would be picking up additional clients that this nurse was no longer caring for. 3. Incorrect: Oh my! Would we really consider allowing this impaired nurse to continue to care for clients for 6 months without intervention while we "observe" the actions of the nurse? This would not be a very good idea. Keep in mind that impaired nurses can lose their usual ability to provide safe, competent client care. Although nurses may be working under the influence of a substance, they retain accountability for their actions and cannot use impairment as a legal defense if harm occurs to a client. So we should certainly not allow the nurse to continue working without investigation and/or intervention. 4. Incorrect: I know that not jeopardizing client care sounded nice, but avoiding confrontation with the nurse will not help to fix this problem. Although it can be very difficult to suspect a co-worker of being impaired or abusing substances, especially when fear of retaliation may be present, nurses should know that they have a responsibility to report any suspicion of such activity to nursing management.

An elderly client diagnosed with terminal cancer is the sole caregiver to a developmentally delayed adult child. The client is worried that the child, with a developmental age of seven years old, will need permanent placement in a long term care facility. What statement by the nurse is most accurate? 1. "Your child will need to be under constant supervision." 2. "A supervised group home would be an ideal setting." 3. "Maybe we could find someone to take in your child." 4. "We should start getting the child used to living alone."

2. Correct: With a developmental age of seven years old, group home supervision would be ideal. The adult child can complete most activities of daily living and will only need minimal assistance with such tasks as cooking, laundry or shopping. 1. Incorrect: This comment is inaccurate, based on Erikson's stages. Even a seven year old can manage most ADLs without assistance, such as bathing, dressing, and grooming. Constant supervision would not be necessary. 3. Incorrect: Take in implies the child would need a private individual to provide care round the clock in a home, which is not necessary for this individual's developmental age. There are many activities the adult child can complete without supervision, so private home placement is not needed. 4. Incorrect: An adult with a mental age of seven is not capable of living completely alone. While able to complete ADLs and many small tasks, this individual would not be able to be live independently.

A nurse manager has recognized that nurses on one shift do not seem to be working well together and, on occasions, refuse to help each other when needed. What strategy could the nurse manager use that would help with team building? Select all that apply 1. Avoid discussing conflicts to build a positive work environment. 2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication.

2., 3., 4., 5., and 6. Correct: The nurse manager needs to incorporate strategies that are effective in team building. One important thing that a nurse manager can do when trying to get nurses to work as a team is to actually model behaviors that promote trust and create a caring environment for not only the clients, but also the nurses and other staff as well. Trust is a cornerstone when trying to build team relationships. In order for nurses to recognize a need for teamwork and reduce conflict, they should have a clear understanding of the unit and agency mission and purpose. The unit manager should assure that this is clearly documented and articulated to the nurses and staff on the unit. The nurse manager should help each nurse and staff member understand how they fit into the overall purpose and goals of the unit and agency. We all know that recognition tends to foster positive behaviors. The nurse manager should recognize nurses who demonstrate commitment to team efforts. This can be done with tangible or nontangible rewards. So, why should nurses be made aware of the messages being sent to the other team members by their behaviors? These nurses may not realize how their unwillingness to work as a team negatively impacts the healthcare team as a whole. They may think that as long as they take care of their clients the way that they want to, everything should be fine. Nurse managers can help nurses to see how their behaviors affect client care and team relations. Once the nurses have agreed upon the roles and responsibilities as part of the healthcare team and understand the lines of communication, they are more likely to follow through with these. Communication by the nurse manager will be crucial in carrying out this team building strategy where all team members agree upon what needs to be accomplished and who to communicate with along the way. 1. Incorrect: It is the nurse manager's responsibility to address the conflict and issues that arise. Failure of the nurse manager to address conflicts within the workplace often fuels more conflict. In addition, the team members often lose respect for the nurse manager who does not discuss and help to resolve the issues. Conflict avoidance can have long term effects on the nursing unit and the agency and can stifle productivity and success of the unit.

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? Select all that apply 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3. & 5. Correct: Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN. These are tasks that must be performed by the RN. The LPN can reinforce teaching. 1. Incorrect: Medication administration is within the LPN scope of practice and can be completed by the LPN. 2. Incorrect: Dressing changes may be delegated to the LPN as this is within the LPN scope of practice. 4. Incorrect: The LPN may call lab results to the primary healthcare provider because this is within the scope of practice for the LPN. If any additional prescriptions are required, the LPN can take these prescriptions over the phone.

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Correct. Administering the client's blood pressure medicines are aimed at correcting the hypertension. The therapeutic action of furosemide is diuresis which will lower the blood pressure. Enalapril is an angiotensin converting enzyme (ACE) that treats hypertension. These medications can be administered within 30 minutes of 0900. 1. Incorrect. Assisting the client back to bed is appropriate, but does not address the problem of lowering the client's BP. Administration of furosemide and enalapril will benefit the client with hypertension. 2. Incorrect. Retaking the BP in the opposite arm is within the scope of practice of an UAP, but does not address the problem of lowering the client's blood pressure. Additionally this should be completed prior to 15 minutes time. The priority is to get the BP down by giving the prescribed medications for hypertension. 4. Incorrect. The LPN can ask the client if they have chest pain. The client does have a BP of 198/94 which could lead to chest pain. The priority is to get the BP down to decrease the risk of complications associated with hypertension, such as MI, and stroke.

While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.

3. Correct: A new nurse should assess this client first because we are worried about hemorrhage. If the fundus is boggy, a fundal massage will need to be done. Assess vital signs for hemorrhage. 1. Incorrect: Clots smaller than a silver dollar are normal. However, do not ignore any bleeding. Always assess the client with any signs of bleeding to determine that the problem is significant. 2. Incorrect: Breastfeeding causes the release of endogenous oxytocin from the pituitary, which causes the uterus to contract. When the uterus contracts, the client may call this discomfort, cramping. This is a normal process necessary for the uterus to return to normal. 4. Incorrect: A post epidural headache can be an indication of inadvertent puncture of the dural membrane. This client will need to be positioned prone, push fluids, given caffeine and may need a blood patch to seal the dural leak.

Which task would be appropriate for the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse to assign to an LPN/LVN? 1. Administering IV pain medication to a client three days postoperative cesarean section. 2. Drawing a trough vancomycin level on a client 3 days postpartum with bilateral mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Drawing routine admission labs on a client admitted in final stages of labor.

3. Correct: Client teaching may be reinforced by an LPN/LVN on a stable client. 1. Incorrect: Administering IV pain medications is out of the scope of practice of LPN/LVN. 2. Incorrect: Drawing lab work on a client with severe infection and only 3 days postpartum is an unstable client and needs care from the RN. 4. Incorrect: Drawing routine admission labs on a client in final stages of labor would be inappropriate because the client is potentially unstable and needs experienced LDRP nursing care.

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information? 1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you.

3. Correct: Each client's health information is confidential and protected by law. The nurse should inform the client's wife of this fact, and explain the rationale for health information confidentiality. Family members are often offended or angry upon learning that health information cannot be released to them without the client's consent , but healthcare employees are bound by law to confidentiality. 1. Incorrect: The wife is not automatically able to receive personal health information about her husband.The husband has to list the wife as a person who can receive personal health information. The Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential without the client's consent. 2. Incorrect: Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential without the client's consent. 4. Incorrect: A client who has received sedative medications cannot give legal consent, as these medications alter a client's level of consciousness and impair the ability to make informed decisions.

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

3. Correct: Reminding clients to follow through on teaching performed by the RN such as to avoid cold foods and smoking would be an appropriate task for the UAP. 1. Incorrect: Sharing successful anxiety reduction measures is teaching. This is the role of the RN and would not be appropriate to delegate to the UAP. 2. Incorrect: Although encouraging a client to express concerns about the possibility of having an ileostomy sounds like something that could be assigned to the UAP, this would require assessment of the client's concerns and should be performed by the RN. 4. Incorrect: Explaining the rationale for needing a low residue diet is teaching. This is outside the scope of practice for the UAP. The RN should retain all tasks related to teaching.

Which activity by the unlicensed assistive personnel (UAP) assisting a client with Parkinson's disease would require intervention by the nurse? 1. Assisting the client with ambulating to the bathroom and back to bed 2. Reminding the client not to look down while walking 3. Performing bathing and oral care for the client 4. Encouraging the client to feed self

3. Correct: The UAP should encourage the client to be as independent as possible. The nurse should intervene and teach UAP about client performing as much care as possible to encourage independence. 1. Incorrect: The UAP should assist the client when ambulating. This would not require intervention. 2. Incorrect: The UAP should remind the client to watch the horizon and not look down. This would not require intervention. 4. Incorrect: The UAP is encouraging independence. This is appropriate intervention and would not require intervention.

The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.

3. Correct: The issue in this scenario is safety. Whether the nurse manager knows this client is not important at the moment. Liquid on the floor poses a safety hazard for clients, visitors, and staff. The priority action is to remove this risk immediately before an injury occurs. 1. Incorrect: Even though the nurse does not recognize this particular client, the priority concern is not focused on identifying this individual. 2. Incorrect: While the client will certainly need clean, dry clothes, the most immediate concern is a safety issue. The nurse can summon a UAP to help the client after addressing the safety issue. 4. Incorrect: The identity of the client is not the initial priority at this time. Consider the whole picture when thinking about safety.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. One important aspect is encouraging the flow of ideas between management and staff members. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. When staff do not feel vested in any new process, there is a sense of underappreciation. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 2. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Assigning blame for the changes to administration will not help staff adjust.

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

3. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. This client is at a high risk of infection. We see that the temperature is already elevated, which makes us worry that infection is present. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 1. Incorrect: Although the potassium level of 3.4 mEq/L (3.4 mmol/L) is slightly decreased, this level can be corrected and should improve when the vomiting and diarrhea subside. The nurse should continue to monitor the potassium level, but it does not take priority over the extremely low ANC in the child with fever. 2. Incorrect: This platelet level of 95,000/mm3 is below the normal range of 150,000/mm3 to 400,000/mm3. When the level gets below 100,000/mm3, the clients should be monitored for bleeding such as a nose bleed, which this client has. However, nose bleeds are not that uncommon and can often be controlled by applying pressure to the nares for 5 to 10 minutes. We would not expect to see severe hemorrhage until the levels are much lower, so this client would not be a priority over the client with the low ANC with fever. 4. Incorrect: This hemoglobin level of 9 g/dL (90 g/L) in a child who has reported fatigue is below the normal of 11-15 g/dL (110-150 g/L). However, the fatigue can be managed by regulating the activity to conserve oxygen expenditure and prevent fatigue. The child with the low absolute neutrophil count with signs of an advancing infection would take priority over this child with a slightly low hemoglobin.

A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowler's position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."

3. Correct: Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration. The client should be sitting upright and fed small amounts of food slowly, allowing time for chewing and swallowing. This statement indicates the UAP understands proper feeding protocols. 1. Incorrect: Semi-fowler's is a "semi-reclining" position, which would greatly increase the risk of aspiration during meals. This comment indicates the UAP would need further instruction. 2. Incorrect: It is crucial to encourage a stroke client to participate as much as possible in self-care, including feeding and bathing. If this client is capable of using utensils, such as modified silverware, it is important to allow as much participation in activities of daily living (ADL) as possible. If the UAP made this comment, further teaching is indicated. 4. Incorrect: Liquids after every bite would quickly fill up the client, decreasing the amount of food intake. Feeding slowly and allowing the client time to swallow after each bite is sufficient for digestion. Such a statement from the UAP means further instruction is needed.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

3., 5., & 6. Correct: The UAP is trained on use of routine equipment such as pneumatic compression devices and can reapply the device to a client. Gathering needed equipment and supplies is within the scope of duties for the UAP. Repositioning a client every 2 hours is within the UAP's ability and can be assigned by the nurse. 1. Incorrect: The UAP can provide routine hygiene. The nurse would be responsible for wound care, including halo insertion pin site care. This requires skill beyond the UAP's knowledge. 2. Incorrect: The UAP cannot administer medications. 4. Incorrect: The UAP cannot assess or evaluate a client. The RN most do this part of the nursing process.

How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care. These clinical pathways reduce the degree of variation in clinical practice, improves outcomes, and promote organized and effective client care based on evidence based practice. Clinical pathways are different from algorithms, practice guidelines, and protocols because they incorporate a multidisciplinary team approach and focus on coordination and quality of care. 1. Incorrect: A decision-making flowchart that uses the if/then method is the definition of an algorithm. The algorithm direction changes based on the information gained at each level of the algorithm, so decisions for actions will be different. 2. Incorrect: A set of practice guidelines developed by professional medical organizations is the definition of a practice guideline. These guideline assist in decision making about appropriate healthcare for specific clinical situations but are not fixed protocols that are designed to be followed in an exact manner. They are recommendations for consideration. The practice guidelines are specific to practice areas rather than having a multidisciplinary approach. 3. Incorrect: A standardized set of preprinted primary healthcare provider prescriptions. These preprinted prescriptions are available for immediate access and use with clients, include commonly prescribed interventions, and reduces oversight of interventions by having a standardized format. Other advantages have also been identified for the use of preprinted prescriptions.

A tour bus is involved in an accident, sending several clients to the emergency room (ER) for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the ER narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.

4. Correct: All personal valuables in the possession of an unconscious client, including money or jewelry, must be tallied in the presence of two nurses and then documented in the client's main chart. Valuable items such as watches, rings or necklaces must also be secured until a family member is contacted, or the client is able to designate disposition of same. With large amounts of cash, a passport or other such important items, it is vital to account for and secure those items until returned to client or family. When dealing with money, two nurses must count the cash and document the total on the client's chart. The funds are then locked in the main hospital safe until the client is discharged or delegates a family member to retrieve same. 1. Incorrect: Even though the client's belongings bag is personal property, it is not a secure location. The bag is usually kept in the client's room or closet which does not provide security for a large amount of money. 2. Incorrect: While locking the cash into the ER narcotics drawer may be a temporary solution during care of the client, this is not an adequate long-term solution. The client will be sent to the operating room, and then admitted to a room. The money is personal property which should remain with the client in a secured manner. 3. Incorrect: Entrusting the funds to a single individual, even the facility CEO, is not the appropriate method of securing valuables.

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. Correct: Clients' rights (still referred to in a hospital setting as the" Patient Bill of Rights") is a written code of ethical behavior describing the relationship that exists between the client and any facility to which they are admitted, including mental health units and hospice care. These guidelines provide the client a specified level of expectations regarding, for example, access to care, confidentiality and personal dignity. Regardless of the circumstances of the disease or location of treatment, clients have the right to refuse care from any professional personnel, including medical and nursing students. 1. Incorrect: Implied consent is an inferred agreement in which medical interventions are provided when the client cannot formally agree, as in the case of unconsciousness or incompetence. However, this client is clearly conscious and able to choose whether care by students is acceptable. The fact that the facility is a teaching hospital in no way deprives this client of the right to refuse student involvement. 2. Incorrect: The issue is the client's rights were violated when medical students were allowed involvement in this case without express consent or acknowledgement by the client. This response by the nurse ignores the client's rights or feelings by focusing on student abilities to provide care. It is demeaning to the client and does not address the client's concerns or provide alternatives. 3. Incorrect: Alerting the primary healthcare provider will be one component needed to resolve this situation. However, this initial response by the nurse is inappropriate for two reasons; first, this process transfers care of the client away from the nurse. Secondly, it does not provide the client with specific information about rights or resolutions.

A paralyzed adolescent admitted for decubiti debridement has brought multiple personal electronics, including a laptop, cell phone and video game unit. The nurse notes the family has used extension cords to provide enough electrical outlets. What action by the nurse is most appropriate? 1. Inform family some of the electronics must be taken home. 2. Explain that extension cords are not permitted in a hospital. 3. Notify maintenance to install more outlets in the client room. 4. Ask client to have staff switch equipment in outlets as needed.

4. Correct: Extension cords are considered a safety hazard in the hospital setting, especially when provided by the family. The nurse has provided an alternative in order for the client to use personal equipment. Staff will assist the client to switch equipment when requested. 1. Incorrect: The nurse is violating the client's right to keep personal belongings while providing no alternative suggestion for the client. Additionally, the nurse has not addressed the use of extension cords in the hospital. 2. Incorrect: Though the nurse is making an accurate statement, no alternative plan has been offered to help meet the client's needs. 3. Incorrect: It is not possible to have maintenance perform construction in a room currently occupied by a client. Installing outlets for one client is not feasible.

A child is admitted to the emergency department due to suspected ruptured appendicitis with perforation. What would be the priority nursing assessment for this client? 1. Monitor for the Rovsing sign. 2. Assess for an increase in temperature. 3. Check for rebound tenderness at McBurney's point. 4. Monitor for increasing pain and rigidity of the abdomen.

4. Correct: Increasing pain and rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis developing. 1. Incorrect: The Rovsing Sign results in RLQ pain that occurs with palpation of the LLQ. This suggests peritoneal irritation due to palpation of a remote location and would indicate appendicitis. 2. Incorrect: Although children with appendicitis may have an elevated temperature, the priority would be assessing for the signs of peritonitis which include increasing pain and rigidity of the abdomen. Children can have an increased temperature with many different types of inflammation and infections. 3. Incorrect: Although rebound tenderness at McBurney's point is indicative of appendicitis, the nurse should not check for this due to the possibility of rupturing the appendix.

What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Inform the client of the need to avoid irritants such as carbonated beverages. 2. Ask client if they are eating small, frequent meals. 3. Monitor for GI upset 30 minutes after meals. 4. Remind the client to avoid tight fitting clothes.

4. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 1. Incorrect: Informing is the same thing as teaching. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 2. Incorrect: The RN is responsible for collecting data. 3. Incorrect: The RN is responsible for assessment and evaluation.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Correct: The nurse must notify the primary healthcare provider immediately about the client's desire to leave without care. The client cannot be physically prevented from leaving, or threatened with possible dire consequences by the nurse. The primary healthcare provider can explain potential risks of non-treatment and obtain a signature on the AMA form. 1. Incorrect: The client must be informed about the potential risks of leaving without medical treatment and that information is best explained by either the emergency room healthcare provider or primary healthcare provider based on knowledge of the client's potential injuries. 2. Incorrect: An "Against Medical Advice" (AMA) form is designed to protect staff and facility from potential litigation filed by clients leaving without treatment. However, a client cannot be forced to sign the form and this is not the nurse's priority action. 3. Incorrect: The nurse can use therapeutic techniques to discuss the situation and try to discover why the client wants to leave. However, there is another priority more important for the nurse.

A client with a history of schizophrenia is currently being treated in a mental health facility. The client wants to vote in an upcoming election. The nurse understands what is true about the legality of this action? 1. Primary healthcare provider can decide if client may vote. 2. Psychiatric clients cannot vote if taking medication. 3. A lawyer must approve the finished ballot. 4. An absentee ballot from the polling place can be obtained.

4. Correct: There are very few reasons that a United States citizen would lose the right to vote in any election, and those few are mostly legal violations. A client who is hospitalized, whether in a medical or psychiatric facility, still retains the right to vote. The nurse, or facility designee, must advocate for this client by obtaining an absentee ballot, following the laws of that state, and is required to provide privacy for the client to complete that ballot. 1. Incorrect: The primary healthcare provider has no authority over the client's ability to cast a vote. Regardless of any mental health diagnosis, this client still retains the legal right to vote in any election. In fact, notifying the primary healthcare provider of the client's intent to vote violates the client's privacy. 2. Incorrect: Whether a client takes medication does not affect the client's right to cast a ballot in any election. Refusing this client, the right to vote based on medication use would be considered discriminatory. 3. Incorrect: A lawyer is not required to approve either the client's voting rights, or the completed ballot. In fact, having anyone else look at the client's ballot would be a violation and is definitely illegal. A client's ballot is private and protected by both state and federal law.

A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu like symptoms progressively worsening over the past 24 hours.What action is most important for the nurse to initiate? Exhibit: Client's Chief Complaint: "I have the flu. I have been vomiting every couple of hours, running a fever and my chest hurts." Vitals Signs: Pulse-132 beats/minute Respirations-26 breaths/minute Blood pressure-94/60 mmHg Temperature-101.3° F (38.5°C) orally Capillary refill - 4 seconds Primary Healthcare Provider Prescription: Rapid Influenza Diagnostic Test Normal Saline 1 liter at 250 mL/hour, then Normal Saline at 100 mL/hour. Chest X-ray Acetaminophen 500 mg po now. 1. Administer acetaminophen. 2. Initiate IV of Normal Saline at 250 mL/hour. 3. Notify radiology and lab of diagnostic test prescriptions. 4. Discuss IV prescription with primary healthcare provider.

4. Correct: This client needs fluid because of dehydration, but did you notice that this client is elderly and has a history of cardiac problems? I hope so, because giving this client NS rapidly could throw our heart client into pulmonary edema, which would be a bad thing! Talk to the primary healthcare provider. 1. Incorrect: Acetaminophen needs to be administered but it is not the most important thing for the nurse to do. Clarification regarding the IV fluid prescription is necessary here to prevent a possible complication. 2. Incorrect: If this client receives an isotonic IV solution at this rapid rate, the client will be at increased risk of developing FVE and pulmonary edema. 3. Incorrect: Again, the radiology and lab departments can be notified of the test prescriptions to be completed. However, the nurse can assign this task to the unit secretary.

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. Client with blunt trauma to the spine that is unable to move extremities. Client with traumatic amputations with agonal respirations. Client with an open chest wound that is beginning to show signs of tracheal deviation. Drag and Drop the items from one box to the other

The client with an open chest wound should be seen first. This client is one whose life could potentially be spared if lifesaving measures are taken. This client may be developing a tension pneumothorax and may need an immediate needle decompression. The client would also need a dressing that is taped down on 3 sides applied over the open chest wound. The second client to be seen is the one with blunt trauma to the spine. Although this client needs emergency treatment as soon as possible due to having probable spinal injury with paralysis, this client's condition is not likely to deteriorate as fast as the client with the open chest wound who is developing a tension pneumothorax. The third client to be assess by the nurse should be the client with the laceration. Did you see laceration with bleeding and think that something would have to be done immediately? Well, there is only moderate bleeding, so although this client needs obvious treatment, this client can wait and would not be a priority over the clients with the open chest wound and blunt trauma to the spine. The last client to be assessed should be the client with agonal respirations. Although this client is still alive, during a mass casualty, the nurse would recognize that the client has agonal respirations and would not have a very good chance of survival with intervention. This client would not take priority over a critical client who has a better chance of survival.

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? Client eating a simple-carb snack due to weakness. Client scheduled for a dressing change to foot ulcer. Client to receive dietary education. Client reporting a headache and has a fruity breath. Drag and Drop the items from one box to the other

The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Remember, pick the killer answer first! This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). What was the hint? Fruity breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.