MedSurg: Prioritization Ch 15 Comprehensive Ex

The nurse is preparing to administer the client's first intravenous antibiotic. Prioritize the nurse's actions from first (1) to last (5). 1. Check the healthcare provider's order in the chart. 2. Determine if the client has any known allergies. 3. Hang the secondary IV piggyback higher than the primary IV. 4. Set the intravenous pump at the correct rate. 5. Determine if the antibiotic is compatible with the primary IV.

Correct Answer: 1, 5, 2, 3, 4 1. This is the first intervention the nurse should implement. Checking the HCP's order is priority. 5. This is the second intervention; the nurse should not administer the antibiotic if it is not compatible with the primary IV. 2. This is the third intervention the nurse should implement. Determining if the antibiotic is compatible is second, because client allergies won't be assessed if the medication is not compatible. 3. This is the fourth intervention. The secondary piggyback (antibiotic) must be hung above the primary IV bag so the secondary piggyback will infuse. 4. This is the fifth intervention. Ensuring the right rate is necessary prior to starting the infusion.

The nurse in the burn unit is preparing to perform a wound dressing change at the bedside. Which interventions should the nurse implement? Rank in order of priority. 1. Obtain the needed supplies for the procedure. 2. Explain the procedure to the client. 3. Remove the old dressing with non-sterile gloves. 4. Medicate the client with narcotic analgesics. 5. Assess the client's burned area.

Correct Answer: 2, 4, 1, 3, 5 2. The nurse should always explain the procedure to the client even if the client has had the procedure done before. 4. This procedure is very painful and the nurse should premedicate the client 30 minutes prior to performing wound care. 1. Obtaining the needed supplies can be done after premedicating the client since the nurse should wait 30 minutes after medicating the client. 3. The nurse should remove the old dressing. 5. The nurse should assess the burned area for signs of infection, viable tissue, or any eschar.

The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? 1. Systems that make it difficult for the nurses to do their job. 2. How unhappy the nurses are with their current pay scale. 3. Collective bargaining activity at a nearby hospital. 4. The number of medication errors committed by an individual nurse.

Correct answer: 1 1. A quality improvement project looks at the way tasks are performed and attempts to see whether the system can be improved. A medication delivery system in which it takes a long time for the nurse to receive a STAT or "now" medication is an example of a system that needs improvement, and should be addressed by a quality improvement committee. 2. Financial reimbursement of the staff is a management issue, not a quality improvement issue. 3. Collective bargaining is an administrative issue, not a quality improvement issue. 4. The number of medication errors committed by a nurse is a management-to-nurse issue and does not involve a systems issue, unless several nurses have committed the same error because the system is not functioning properly.

The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

Correct answer: 1 1. A secondary nursing intervention includes screening for early detection. The bone density evaluation will determine the density of the bone and is diagnostic for osteoporosis. 2. Spinal screening examinations are performed on adolescents to detect scoliosis. This is a secondary nursing intervention, but not to detect osteoporosis. 3. Teaching the client is a primary nursing intervention. This is an appropriate intervention to help prevent osteoporosis, but it is not a secondary intervention. 4. Discussing risk factors is an appropriate intervention, but it is not a secondary nursing intervention.

The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering? 1. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery. 2. The anticoagulant enoxaparin (Lovenox) to a client who had a TKR. 3. The sliding scale insulin Humalog to a client who had a Whipple procedure. 4. The aminoglycoside vancomycin to a client allergic to the antibiotic penicillin.

Correct answer: 1 1. Antiplatelet medication will increase the client's bleeding time and should be held 5 days prior to surgery; therefore, this medication should be questioned. 2. A client with a TKR is at risk for developing deep vein thrombosis (DVT); therefore, an anticoagulant medication would not be questioned. 3. The client with a Whipple procedure has had part of the pancreas removed and is placed on insulin; therefore, the nurse would not question administering Humalog. 4. An aminoglycoside antibiotic is not in the penicillin family; therefore, the nurse would not question administering this medication.

The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? 1. Evaluate the job performance of the staff. 2. Be the sole decision maker for the unit. 3. Take responsibility for the staff nurse's actions. 4. Attend the medical staff meetings.

Correct answer: 1 1. One of the many jobs of a manager is to see that performance evaluations are completed on the staff. 2. The manager should receive input from many sources to make decisions. Some decisions are made for the manager by administration based on costs or any number of other reasons. 3. The nurses retain responsibility for their own actions because they practice under the state's nursing practice act. The manager retains responsibility for the functioning of the unit. 4. The nurse manager attends many meetings pertaining to nursing but attends medical committee meetings only when a nursing issue is being discussed.

The unlicensed assistive personnel (UAP) accidentally pulled the client's chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? 1. Securely tape petroleum gauze over the insertion site. 2. Instruct the UAP how to move a client with a chest tube. 3. Assess the client's respirations and lung sounds. 4. Obtain a chest tube and a chest tube insertion tray.

Correct answer: 1 1. Taping petroleum gauze over the chest tube insertion site will prevent air from entering the pleural space. This is the first intervention. 2. The nurse should make sure the UAP knows the correct method to assist a client with a chest tube, but the safety of the client is the first priority. 3. This is the second intervention the nurse should implement. Remember, if the client is in distress and the nurse can do something to relieve that distress, then the nurse should not assess first. The nurse should take action to take care of the client. 4. The nurse should obtain the necessary equipment for the HCP to reinsert the chest tube, but the priority intervention is to prevent air from entering the pleural space.

A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement? 1. Tell the HCP that the jokes are inappropriate and offensive. 2. Report the behavior to the medical staff committee. 3. Discuss the problem with the chief nursing officer. 4. Call a Code Purple and have the nurses surround the HCP.

Correct answer: 1 1. Telling jokes with sexual innuendos creates a "hostile work environment" and should be addressed with the HCP. This is a courtesy to the HCP to allow him to correct the behavior without being embarrassed. 2. If the behavior is not corrected, then the nurse should report the HCP to the manager or chief nursing officer (CNO). The manager or CNO may find it necessary to report the behavior to the medical staff committee or president. 3. The charge nurse should first report the behavior to the manager and then, if the problem is not resolved, to the CNO; in other words, follow the chain of command. 4. Some facilities have a code for staff to use when an HCP is acting out, but it is rarely, if ever, used.

The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? 1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. 2. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau's sign.

Correct answer: 1 1. The Glasgow Coma Scale ranges from 0 to 15, with 15 indicating the client's neurological status is intact. A Glasgow Coma Scale score of 13 indicates the client is stable and would be the most appropriate client to assign to the graduate nurse. 2. This client's K+ level is low, and the client is at risk for developing cardiac dysrhythmias; therefore, the client should be assigned to a more experienced nurse. 3. This client has a low blood pressure and evidence of tachycardia and could possibly go into an Addisonian crisis, which is a potentially life-threatening condition. A more experienced nurse should be assigned to this client. 4. A positive Trousseau sign indicates the client is hypocalcemic and is experiencing a complication of the surgery; therefore, this client should be assigned to a more experienced nurse.

The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? 1. Instruct her to assist the client with a shower. 2. Ask her to prepare the breakfast meal for the client. 3. Request her to take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

Correct answer: 1 1. The HH aide's responsibility is to care for the client's personal needs, which includes assisting with a.m. care. 2. The HH aide is not responsible for cooking the client's meals. 3. The HH aide is not responsible for taking the client to appointments. This also presents an insurance problem, because the client would be riding in the HH aide's car. 4. Even in the home, the HH nurse should not delegate teaching.

The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? 1. Administer PO medications to a client diagnosed with gastroenteritis. 2. Take the routine vital signs for all the clients on the pediatric unit. 3. Transcribe the HCP's orders into the computer. 4. Assess the urinary output of a client diagnosed with nephrotic syndrome.

Correct answer: 1 1. The LPN can administer routine medications. 2. The UAP, not the LPN, should be assigned to take the routine vital signs. 3. The unit secretary, not an LPN, should be assigned to transcribe the HCP orders. 4. The RN, not the LPN, should assess the urinary output of the client. The RN should not delegate assessment.

The charge nurse in an extended care facility notes an elderly male resident holding hands with an elderly female resident. Which intervention should the charge nurse implement? 1. Do nothing, because this is a natural human need. 2. Notify the family of the residents about the situation. 3. Separate the residents for all activities. 4. Call a care plan meeting with other staff members.

Correct answer: 1 1. The charge nurse does not have a right to interfere with two consenting adults having a relationship. Doing nothing is the correct action for the charge nurse. If one of the residents involved is incapable of giving consent to a relationship, then the charge nurse would need to get involved. 2. Two consenting adults have a right to form a bond. The family does not have a right to interfere with the expression of a basic human need, to form an intimate relationship with another human being. 3. The residents have the right to companionship. They should be allowed to participate in any activity that they wish, when they wish. 4. This is a normal situation, and no care plan meeting is needed.

The charge nurse overhears two unlicensed assistive personnel (UAPs) discussing a client in the hallway. Which action should the charge nurse implement first? 1. Remind the UAPs that clients should not be discussed in a public area. 2. Tell the unit manager that the UAPs might have been overheard. 3. Have the UAPs review policies on client confidentiality and HIPAA. 4. Find some nursing tasks the UAPs can be performing at this time.

Correct answer: 1 1. The charge nurse should remind the UAPs not to discuss confidential information in a public place. This is the first action. 2. The charge nurse may need to inform the manager of the breach of confidentiality, but the first action is to stop the conversation. 3. The charge nurse and/or the manager may need to make sure the UAPs are familiar with confidentiality, but the conversation should be terminated first. 4. This might be a better activity for the UAPs, but the first action is to stop the conversation.

The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client? 1. Restrain the client's wrists, as needed. 2. Offer the client fluids every 2 hours. 3. Apply a hand mitt to the arm opposite the IV site for 12 hours. 4. Check circulation of the restrained limb every 2 hours.

Correct answer: 1 1. The client cannot be restrained as needed. The nurse must have documentation for the need and an HCP's specific order that includes reason for restraint and time limited to no more than 24 hours. This HCP order should be clarified. 2. The client in restraints should be offered fluids at least every 2 hours. 3. Hand mitts are the least restrictive limb restraints and can be used to help prevent the client from pulling out lines. 4. The nurse must check to ensure that restrained limbs have adequate circulation at least every 2 hours.

The resident in a long-term care facility tells the nurse, "I think my family just put me here to die because they think I am too much trouble." Which statement is the nurse's best response? 1. "Can you tell me more about how you feel since your family placed you here?" 2. "Your family did what they felt was best for your safety." 3. "Why would you think that about your family? They care for you." 4. "Tell me, how much trouble were you when you were at home?"

Correct answer: 1 1. The client is expressing negative feelings about being placed in the nursing home. Asking about the client's feelings is a therapeutic response that encourages the client to discuss his or her feelings. 2. This is not acknowledging the client's feelings and is nontherapeutic because it is a judgmental statement. 3. The client does not owe the nurse an explanation. "Why" is never therapeutic. 4. This is assuming the client is correct in being "trouble at home" and agreeing that the family would punish the client for being a problem.

The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first? 1. Determine whether the client has grab bars in the bathroom. 2. Encourage the client to take a shower instead of a bath. 3. Initiate a referral to a physical therapist for the client. 4. Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

Correct answer: 1 1. The first intervention is for the nurse to ensure the client is safe in the home. Assessing for grab bars in the bathroom is addressing the safety of the client. 2. Taking a shower in a stall shower may be safer than getting in and out of a bathtub, but the nurse should first determine whether the client has grab bars and safety equipment even when taking a shower. 3. According to the NCLEX-RN® test blueprint for management of care, the nurse must be knowledgeable of referrals. The physical therapist is able to help the client with transferring, ambulation, and other lower extremity difficulties and is an appropriate intervention, but it is not the nurse's first intervention. Safety is priority. 4. NSAIDs are used to decrease the pain of osteoarthritis, but this intervention will not address safety issues for the client getting into and out of the bathtub.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The client who had surgery for an inguinal hernia and who is being prepared for discharge. 2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. 3. The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. 4. The client who has end-stage renal disease and who has had an arteriovenous fistula created.

Correct answer: 1 1. The most experienced nurse should be assigned to the client who requires teaching and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day. 2. A routine preoperative client does not require the most experienced nurse. 3. Any nurse can administer and monitor blood transfusion to the client. 4. Although the creation of an arteriovenous fistula requires assessment and teaching on the part of the most experienced nurse, this client is not being discharged home at this time.

The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider.

Correct answer: 1 1. The nurse should first assess the client prior to taking any other action to determine if the client is experiencing any untoward reaction. 2. An incident report must be completed by the nurse but not prior to taking care of the client. 3. The nurse should administer the correct medication but not prior to assessing the client. 4. The client's HCP must be notified, but the nurse should be able to provide the HCP with pertinent client information, so this is not the first intervention.

The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first? 1. Pre-medicate the client with a narcotic analgesic. 2. Prepare the equipment and bandages at the bedside. 3. Remove the old dressing with non-sterile gloves. 4. Place a sterile glove on the dominant hand.

Correct answer: 1 1. The nurse should first medicate the client since this procedure is very painful for the client. 2. The nurse should prepare the equipment, but not prior to medicating the client. This should be done 30 minutes before procedure starts. 3. The nurse should use non-sterile gloves to remove the old dressing but not prior to medicating the client. 4. The nurse should don sterile gloves (can put one on dominant hand), but not prior to medicating client.

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. 2. The client diagnosed with pneumonia who has an oral temperature of 100.2°F. 3. The client diagnosed with cystitis who complains of burning on urination. 4. The client diagnosed with pancreatitis who complains of pain that is an 8.

Correct answer: 1 1. The therapeutic PTT level should be 11/2 to 2 times the control. Most controls average 36 seconds, so the therapeutic levels of heparin would place the control between 54 and 72. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first. 2. A client diagnosed with pneumonia would be expected to have a fever. This client can be seen after the client diagnosed with a DVT. 3. Cystitis is inflammation of the urinary bladder, and burning on urination is an expected symptom. 4. Pancreatitis is a very painful condition. Pain is a priority but not over the potential for hemorrhage.

The nurse has received the shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom. 2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. 3. The client diagnosed with pancreatitis who wants the nasogastric tube removed. 4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

Correct answer: 1 1. This client is exhibiting signs and symptoms of a potentially fatal complication of DVT—pulmonary embolism. The nurse should assess this client first. 2. Refusing to eat hospital food should be discussed with the client, but the nurse could ask the unit secretary to have the dietitian see the client. 3. Clients diagnosed with pancreatitis have nasogastric tubes to rest the bowel. However, these tubes are typically uncomfortable. Regardless, the nurse should see this client after the client diagnosed with DVT has been assessed and appropriate interventions initiated. The nurse should discuss the importance of maintaining the tube with the client. 4. This is an expected symptom of osteoarthritis. This client does not need to be assessed first.

The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? 1. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough. 2. The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds. 3. The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer. 4. The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis.

Correct answer: 1 1. This client may be developing a complication of immobility, one of which is pneumonia. The nurse should assess this client first. 2. Loss of weight in a client with CHF indicates the client is responding to therapy. This client does not need to be assessed first. 3. Pressure ulcers are a chronic problem, which frequently occur in clients who are paralyzed. This client does not need to be assessed first. 4. Paralysis is expected for a CVA. This client does not need to be assessed first.

Which situation should the charge nurse in the critical care unit address first after receiving the shift report? 1. Talk to the family member who is irate {Furious, mad} over his loved one's nursing care. 2. Complete the 90-day probationary evaluation for a new ICU graduate intern. 3. Call the laboratory concerning the type and crossmatch for a client who needs blood. 4. Arrange for a client to be transferred to the telemetry step-down unit.

Correct answer: 1 1. This situation should be addressed first because the charge nurse is responsible for family/client complaints. If the family contacts the administration, the charge nurse must be aware of the situation. 2. The evaluation needs to be completed, but it does not take priority over handling an irate family member. 3. The charge nurse could assign this task to another nurse or ward clerk. Dealing appropriately with an irate family member takes priority over calling the laboratory. 4. The charge nurse could assign this task to another nurse or ward clerk. Dealing appropriately with an irate family member takes priority over transferring a client.

The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee? 1. Discuss the nurse's actions with the unit manager. 2. Confront the nurse about the behavior. 3. Do not allow the nurse to take breaks alone. 4. Prepare an occurrence report on the employee.

Correct answer: 1 1. Usually, the charge nurse should attempt to settle a conflict at the lowest level possible, in this case, confronting the nurse. However, the charge nurse does not have the authority to require a drug screen, which is the intervention needed in this situation. The nurse should notify the unit manager. 2. The charge nurse does not have the authority to force the nurse to submit to a drug screening, which is what this behavior suggests. Therefore, the charge nurse should not confront the staff nurse. The nurse should notify the supervisor. 3. Nurses have the right to take breaks with or without their peers. The charge nurse cannot enforce this option. 4. An occurrence report is not used for this type of situation. This is a management or a peer review issue. The nurse can go through the manager or a peer review committee.

The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound. 2. Keep the resident's heels off the surface of the bed. 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake.

Correct answer: 1 1. Wound debriding formulations are medications, and a UAP cannot administer medications. 2. The UAP can position the resident so that pressure is not placed on the resident's heels. 3. The UAP can turn the resident. 4. The UAP can give the resident a protein shake to drink.

The client tells the nurse, "I am having surgery on my right knee." However, the operative permit is for surgery on the left knee. Which action should the nurse implement first? 1. Notify the operating room team. 2. Initiate the time-out procedure. 3. Clarify the correct extremity with the client. 4. Call the surgeon to discuss the discrepancy.

Correct answer: 2 1 The nurse should notify the operating room team, but according to the Joint Commission, the first intervention is to call a timeout, which stops the surgery until clarification is obtained. 2. According to the Joint Commission, the first intervention is to call a time-out, which stops the surgery until clarification is obtained. 3. The nurse should discuss this with the client but should first initiate the time-out procedure. 4. Calling the surgeon is a part of the time-out procedure, so the first intervention is to call the time-out.

The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? 1. The nurse who has the most vacation time. 2. The nurse who requested to be off. 3. The nurse who has the least experience on the unit. 4. The nurse who has called in sick the previous 2 days.

Correct answer: 2 1. Staff members will not stay if forced to always use their paid time off for the hospital's convenience. 2. This nurse wants to take time off. Therefore, it is the best option to let the nurse desiring to be off from work to take time off if all other situations are equal. 3. The nurse will not gain experience if always requested not to come to work, and presumably this nurse would not have benefit time to pay for the time out of work. 4. This nurse could be allowed to stay home only if the nurse is still ill.

The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two UAPs for a 12-hour shift. Which task would be an inappropriate delegation of assignments? 1. The RN will perform the shift assessments. 2. The LPN should administer all IVP medications. 3. The UAP will complete all a.m. care. 4. The RN will monitor laboratory values.

Correct answer: 2 1. The RN is responsible for assessing clients; therefore, this is an appropriate assignment. 2. The LPN may be allowed administer some IVP medications in some facilities, but the word "all" makes this an inappropriate assignment. Many IVP medications are considered high risk, and only RNs should administer such IVP medications. 3. This option has the word "all," but it is within the scope of the UAP to complete the a.m. care. The RN and LPN can perform a.m. care, but it should be assigned to the UAP. 4. The RN should monitor laboratory values because this requires interpretation, evaluation, and notification of the HCP in some instances.

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit? 1. Escort the client to the smoking area outside. 2. Obtain vital signs on a newly admitted client. 3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.

Correct answer: 2 1. The UAP is being paid to assist the nurse to care for clients on the surgical unit, not take clients downstairs to smoke. 2. The UAP can take vital signs on a newly admitted client. 3. The client has a tube into the stomach via the abdominal wall that requires assessing the residual to determine whether the stomach is digesting the tube feeding. This task is not appropriate to delegate to the UAP. 4. If the toes are cold, have a capillary refill time of more than 3 seconds, or are pale, the nurse must make a judgment as to the circulatory status of the foot; therefore, the nurse would not delegate this task.

The chief nursing officer (CNO) of an extended care facility is attending shift report with two charge nurses, and an argument about a resident's care ensues. Which action should the CNO implement first? 1. Ask the two charge nurses to stop arguing and go to a private area. 2. Listen to both sides of the argument and then implement a plan of care. 3. Ask the family to join the discussion before deciding how to implement care. 4. Tell the nurses to stop arguing and continue to give report.

Correct answer: 2 1. The argument should already be in a private area because the argument ensued during report. Report should always be held in a confidential area. 2. The CNO should evaluate the concerns of each charge nurse and then make a decision as to a plan of care for the resident. The CNO is the next in command over the charge nurses in an extended care facility. 3. This argument does not involve the family. If, after listening to both sides, the CNO thinks there is a need for a family member's input, then the CNO could contact the family, but a decision should be made until this can occur. 4. The nurses each have a concern over a resident. This situation should be resolved before continuing report.

The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? 1. Ask the charge nurse to teach all the other UAPs. 2. Encourage the nurse to continue to work with the UAP. 3. Tell the charge nurse to discuss this in a private area. 4. Give the UAP a better explanation of the procedure.

Correct answer: 2 1. The charge nurse is not the nurse educator but is responsible for the UAPs working under him or her. This is adding additional duties to the charge nurse. 2. The director of nurses should encourage responsible behavior on the part of all staff. The charge nurse is performing a part of the responsibility of the charge nurse and should be encouraged to work with the UAP. 3. Because this is not a private conversation about a client, there is no reason for the charge nurse to be told to go to a private area. The charge nurse is not reprimanding the UAP. 4. The director of nurses should not interfere with a "better explanation." This could intimidate the charge nurse and make it difficult for the charge nurse to perform his or her duties.

The HCP is angry and yelling in the nurse's station because the client's laboratory data are not available. Which action should the charge nurse implement first? 1. Contact the laboratory for the client's results. 2. Ask the HCP to step into the nurse's office. 3. Tell the HCP to discuss the issue with the laboratory. 4. Report the HCP's behavior to the chief nursing officer.

Correct answer: 2 1. The charge nurse should contact the laboratory, but the first action should be to address the HCP's behavior in a private area. 2. This is the charge nurse's first action because it will diffuse the HCP's anger. Inappropriate behavior at the nurse's station should not occur in an area where visitors, clients, or staff will observe the behavior. 3. The HCP can call the laboratory and share his or her concerns, but it is not the first intervention. 4. The charge nurse has the option to report any HCP's inappropriate behavior, but the immediate situation must be dealt with first.

Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

Correct answer: 2 1. The client on the ventilator is unstable; therefore, the nurse should not delegate any tasks to the UAP. 2. The UAP can take specimens to the laboratory; these are not medications and they are not vital to the client. 3. The client in an Addisonian crisis is unstable; therefore, the nurse should not delegate any tasks to the UAP. 4. The UAP cannot assist the HCP with an invasive procedure at the bedside.

Which client should the nurse in the post-anesthesia care unit (PACU) assess first? 1. The client who received general anesthesia who is complaining of a sore throat. 2. The client who had right knee surgery and has a pulse oximeter reading of 90%. 3. The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse. 4. The client who had abdominal surgery and has green bile draining from the N/G tube.

Correct answer: 2 1. The client who had an endotracheal tube would have a sore throat; therefore, the PACU nurse would not assess this client first. 2. A pulse oximeter reading of less than 93% indicates an oxygenation problem; therefore, this client should be assessed first. 3. Epidural surgery affects the lower extremities, so a palpable pedal pulse indicates a sufficient blood supply; this client should not be assessed first. 4. Drainage of green bile from the nasogastric (N/G) tube is normal; therefore, this client should not be seen first.

The HH aide calls the HH nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Visit the client to assess the reddened area. 3. Document the finding in the client's chart. 4. Refer the client to the wound care nurse.

Correct answer: 2 1. The client's HCP may need to be notified, but it is not the nurse's first intervention. 2. The nurse must first assess the reddened area to determine the stage of the pressure ulcer and what treatment should be recommended. 3. The reddened area should be documented in the chart, but this is not the first intervention. 4. The client may or may not need to be referred to a wound care nurse, but it is not the nurse's first intervention. If the reddened area is Stage 1 or 2, the wound care nurse probably would not be notified.

The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? 1. Have another employee drive the clients home. 2. Notify the public health department immediately. 3. Send the clients to the emergency department. 4. Obtain stool specimens from the clients.

Correct answer: 2 1. The employee health nurse should keep the clients at the clinic or send them to the emergency department. The clients should be kept together until the cause of their illnesses is determined. If it is determined that the clients are stable and not contagious, they should be driven home. 2. The employee health nurse should be aware that six clients with the same signs/ symptoms indicate a potential deliberate or accidental dispersal of toxic or infectious agents. The nurse must notify the public health department so that an investigation of the cause can be instituted and appropriate action to contain the cause can be taken. 3. As long as the clients are stable, the nurse should keep the clients in the employee health clinic. These clients should not be exposed to other clients and emergency department staff. If the clients must be transferred, decontamination procedures may need to be instituted. 4. The client may need to provide stool specimens, but this would be done at the emergency department. Employee health clinics do not have laboratory facilities to perform tests on stools.

The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? 1. Tell the unlicensed assistive personnel (UAP) to ambulate the client with the walker. 2. Request a referral to the physical therapy department. 3. Obtain a walker that is appropriate for the client's height. 4. Notify the social worker of the HCP's order for a walker.

Correct answer: 2 1. The first time a client ambulates after hip surgery should be with a physical therapist or a nurse qualified to evaluate the client's ability to ambulate safely with a walker. The UAP does not have these qualifications. 2. According to the National Council of State Boards of Nursing (NCSBN), collaboration with interdisciplinary team members is part of the Management of Care. Physical therapy is responsible for management of the client's ability to move and transfer. 3. The physical therapist will measure and obtain the correct walker for the client. 4. The social worker is not responsible for assisting the client to ambulate, but may assist the client on discharge in obtaining needed medical equipment in the home.

The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? 1. Reinsert the nasogastric tube for the client who has pulled it out. 2. Complete the preoperative checklist for the client scheduled for surgery. 3. Instruct the client who is being discharged home about colostomy care. 4. Change the client's surgical dressing that has a 20 cm area of drainage.

Correct answer: 2 1. The nasogastric tube should be replaced, but this task will require more time and acquiring new equipment; therefore, it should not be done first. 2. The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client's safety. 3. The client being discharged can wait until the safety needs of the client going to surgery have been addressed. 4. This is a minimal to moderate amount of drainage, which requires a dressing change, but not prior to making sure the client going to surgery is ready.

The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

Correct answer: 2 1. The new graduate must work under this charge nurse; confronting the nurse would not resolve the issue because the nurse can choose to ignore the new graduate. Someone in authority over the charge nurse must address this situation with the nurse. 2. The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation. 3. The new graduate is bound by the nursing practice acts to report potentially unsafe behavior regardless of the position the nurse holds. 4. The nurse educator would not be in a position of authority over the charge nurse.

The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney. 2. Review the client's chart. 3. Purchase personal liability insurance. 4. Discuss the case with the supervisor.

Correct answer: 2 1. The nurse may wish to consult the hospital's attorneys or retain an attorney of his or her own, but this is not the first action for the nurse. 2. The nurse should be familiar with the chart and the situation so that details can be remembered. This should be the nurse's first action. 3. It is too late to purchase liability insurance to cover the current situation. The nurse may wish to purchase insurance for any future litigation. 4. The nurse should refrain from discussing the case with anyone who could be called as a witness or be named in the suit.

The nurse in an assisted living facility notes that the male client has several new bruises on both of his arms and hands. Which intervention should the nurse implement first? 1. File an elder abuse report with the Department of Human Services. 2. Ask the client whether he has fallen and hurt himself during the night. 3. Check the medication administration record (MAR) to determine which medications the client is receiving. 4. Notify the client's family of the bruises so they are not surprised on their visit.

Correct answer: 2 1. The nurse must assess the cause of the bruises before filing a report of abuse. The nurse would file a report of elder abuse only if it is determined that the client has been abused. 2. The nurse should ask the client whether there is a reason for the bruises that the nurse should be aware of. This is the first intervention and can be done while the nurse is currently with the client. 3. The nurse should check the client's MAR to see whether he is currently on a medication, such as warfarin (Coumadin) or a systemic steroid, that would increase the risk for bruising; however, this would be done after talking with the client because the bruising is "new," and bruising from the medications can take several days to weeks to develop. 4. The family may need to be notified but not until the nurse assesses the situation.

The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? 1. Place a Posey vest restraint on the client. 2. Move the client to a room near the station. 3. Ask the HCP for an antipsychotic medication. 4. Raise all four side rails on the client's bed.

Correct answer: 2 1. The nurse should implement the least restrictive measures to ensure client safety. Restraining a client is one of the last measures implemented. 2. Moving the client near the nursing station where the staff can closely observe the client is one of the first measures in most fall prevention policies. 3. This is considered medical restraints and is one of the last measures taken to prevent falls. 4. Four side rails are considered a restraint. Research has shown that having four side rails up does not prevent falls and only gives the client farther to fall when the client climbs over the rails before falling to the floor.

The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? 1. Immediately give a 2-week notice and find a different job. 2. Discuss the situation with the manager who interviewed him. 3. Talk with the other employees about the staffing situation. 4. Tell the charge nurse the staffing is not what was explained to him.

Correct answer: 2 1. The nurse should leave if he determines that the staffing is not now or ever will be as it was relayed to him in the interview; however, there may be a temporary situation that can be resolved. 2. The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such as illness, may be affecting staffing. 3. This action could cause the manager to think of the new nurse as a troublemaker. 4. The nurse should not discuss this with the charge nurse because this may cause a rift between the charge nurse and the new nurse. The nurse should clarify the staffing situation with the unit manager.

The 65-year-old client is being discharged from the hospital following major abdominal surgery and is unable to drive. Which referral should the nurse make to ensure continuity of care? 1. A church that can provide transportation. 2. A home health agency. 3. An outpatient clinic. 4. The healthcare provider's office.

Correct answer: 2 1. The nurse should not refer the client to a church or volunteer organization to ensure continuity of care. The organization's work may depend on unpaid individuals, and a volunteer may or may not be available to transport the client when needed. 2. The nurse should refer the client to a home health agency for follow-up care. The nurse will go to the client's home to assess the client and perform dressing changes. The home health agency will also assess the client and the client's home for further needs. 3. The client is unable to drive and would not be able to get to an outpatient clinic. 4. The client is unable to drive and would not be able to get to the HCP's office.

The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

Correct answer: 2 1. The nurse should stop the behavior from occurring in a public place. The charge nurse can discuss the issue with the UAPs and determine whether the manager should be notified. 2. The first action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs' behavior in public. 3. The second action is to have the UAPs go to a private area before resuming the conversation. 4. The charge nurse may need to mediate the disagreement; this would be the third step.

The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon? 1. The client who is 2 days postoperative for bowel resection and who refuses to turn, cough, and deep breathe. 2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away. 3. The client who is 2 hours postoperative for TKR and who has 400 mL in the cell-saver collection device. 4. The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign.

Correct answer: 2 1. The nurse would not need to notify the surgeon of the client's refusal because this is a situation the nurse should manage. 2. Feeling a "pop" after an abdominal hysterectomy may indicate possible wound dehiscence, which is a surgical emergency and requires the nurse to notify the surgeon via telephone. 3. This situation indicates that it is time for the nurse to reinfuse the lost blood. 4. A negative Chvostek sign is normal and indicates the calcium level is within normal limits.

The 32-year-old male client with a traumatic right above-the-elbow amputation tells the home health (HH) nurse he is worried about supporting his family and finding employment since he can't be a mechanic anymore. Which intervention should the nurse implement? 1. Contact the HH agency's occupational therapist. 2. Refer the client to the state rehabilitation commission. 3. Ask the HH agency's social worker about disability. 4. Suggest he talk to his wife about his concerns.

Correct answer: 2 1. The occupational therapist assists the client with activities of daily living, not with employment concerns. 2. The NCLEX-RN® test blueprint lists referrals under Management of Care. After a client has been injured and is unable to return to previous employment because of the injury, the rehabilitation commission of each state will help evaluate the client and determine whether the client is eligible to receive training or education for another occupation. 3. The client is not asking about disability but rather about employment. The nurse needs to refer the client to the appropriate agency. 4. The client should discuss his concerns with his wife, but the nurse should refer the client to an agency that can address his concerns about employment.

The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first? 1. Discuss the infections with the chief nursing officer. 2. Contact the infection control nurse to discuss the problem. 3. Assume the employee health nurse is monitoring the situation. 4. Volunteer to be on an ad hoc committee to research the infection rate.

Correct answer: 2 1. The staff nurse should go through the chain of command when wanting to investigate a problem. 2. Possibly increasing infection rates among clients with PICCs falls within the infection control nurse's scope of practice, and the infection control nursing staff will have data from all units in the hospital. 3. The nurse should follow through with investigating a potential problem, but this problem does not fall within the scope of practice of the employee health nurse. 4. The staff nurse should be a part of the solution to a problem. Volunteering is a good action to effect change, but it is not the first action. More information—which the infection control nurse can provide—is necessary first.

The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1? 1. The client with head trauma whose pupils are fixed and dilated. 2. The client with compound fractures of the tibia and fibula. 3. The client with a sprained right wrist with a 1-inch laceration. 4. The client with a piece of metal embedded in the right eye.

Correct answer: 2 1. This client should be categorized as black, priority 4, which means the injury is extensive and chances of survival are unlikely even with definitive care. Clients should receive comfort measures and be separated from other casualties but not abandoned. 2. This client should be categorized as red, priority 1, which means the injury is life threatening but survivable with minimal intervention. These clients can deteriorate rapidly without treatment. 3. This client should be categorized as green, priority 3, which means the injury is minor and treatment can be delayed hours to days. These clients should be moved away from the main triage area. 4. The client should be categorized as a yellow, priority 2, which means the injury is significant and requires medical care but can wait hours without threat to life or limb. Clients in this category receive treatment only after immediate casualties are treated.

The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."

Correct answer: 2 1. This might be the second statement for the nurse to make if the client does not calm down and discuss the problems with the nurse. Because it could escalate the anger, it should not be the first statement. 2. The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client. 3. This statement will escalate the situation and could cause the visitor to lash out at the nurse. 4. This statement will escalate the situation and could cause the visitor to lash out at the nurse.

The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

Correct answer: 2 1. This should not be implemented until verification of the allegation is complete, and the shift manager has discussed the situation with the UAP. 2. The shift manager should have objective data prior to confronting the UAP about the allegation of falsifying vital signs; therefore, the shift manager should take the client's vital signs and compare them with the UAP's results before taking any other action. 3. The shift manager should not confront the UAP until objective data are obtained to support the allegation. 4. Written documentation should be the last action when resolving staff issues.

The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit. 1. Extinguish. 2. Rescue. 3. Confine. 4. Alert.

Correct answer: 2, 4, 3, 1 The nurse must remember the acronym RACE, which is a recognized national standard for fire safety in healthcare facilities. 2. R is for rescue. 4. A is for alert. 3. C is for confine. 1. E is for extinguish.

The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? 1. Apply a sterile dressing to a Stage IV pressure wound. 2. Check the blood glucose level of a resident who is weak and shaky. 3. Document the amount of food the residents ate after a meal. 4. Teach the residents how to play different types of bingo.

Correct answer: 3 1. A nurse, not the UAP, should perform sterile dressing changes. 2. This client is unstable, and a nurse should perform this task. 3. The UAP can check to see the amount of food the residents consumed and document the information. 4. This is the job of the activity director and volunteers working with the activities department. Staffing is limited in any nursing area; the UAP should be assigned a nursing task.

The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? 1. Administer a pain medication 30 minutes before therapy. 2. Give the client a washcloth to wash his or her face before walking. 3. Check to make sure the client has been offered the use of the bathroom. 4. Find a walker that is the correct height for the client to use.

Correct answer: 3 1. Administering pain medication is the nurse's responsibility, not that of the UAP. 2. A washcloth should be provided to the client before a meal, but not before ambulating with the physical therapist. 3. The client should be ready to work on therapy when the physical therapist arrives. The UAP should make sure the client has used the bathroom or has not been incontinent before the therapist arrives, thus making the most efficient use of the therapist's time. 4. Obtaining a walker that is the correct height for the client is the physical therapist's responsibility, not that of the UAP.

The unlicensed assistive personnel (UAP) is changing a full sharps container in the client's room. Which action should the nurse implement? 1. Tell the UAP she cannot change the sharps container. 2. Explain the housekeeping department changes the sharps containers. 3. Praise the UAP for taking the initiative to change the sharps container. 4. Report the behavior to the clinical manager on the unit.

Correct answer: 3 1. Any member of the staff can change the sharps container when it is full. There is an OSHA fine if the sharps containers are over the full line. 2. The housekeeping department can change the sharps container as well as any staff member. 3. The nurse should reward appropriate behavior by the other healthcare members. Verbal praise is always appreciated by anyone. 4. The nurse could let the clinical manager know the UAP was emptying the sharps container but the best action is to directly praise the UAP.

The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit? 1. Send the unlicensed assistive personnel (UAP) who has worked on the surgical unit for 5 years. 2. Send the RN who has worked in the hospital for 8 years in a variety of areas. 3. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit. 4. Send the new graduate nurse who is orienting to the surgical unit.

Correct answer: 3 1. Because there are multiple surgical clients requiring custodial care, the charge nurse should not send an experienced UAP to the medical unit. 2. The charge nurse should not send the experienced RN to the medical unit because this nurse represents the strength of the staff. 3. The LPN would be the most appropriate staff to send to the medical unit because the LPN has experience on the unit. His or her expertise is also not required to perform custodial care. 4. A new orientee should not be sent to an unfamiliar area.

Which action by the nurse is a violation of the Joint Commission's Patient Safety Goals? 1. The surgery nurse calls a time-out when a discrepancy is noted on the surgical permit. 2. The unit nurse asks the client for his or her date of birth before administering medications. 3. The nurse educator gives the orientee the answers to the quiz covering the IV pumps. 4. The admitting nurse initiates the facility's fall prevention program on an older adult client.

Correct answer: 3 1. Calling a time-out when a discrepancy is noted on the surgical permit is an appropriate action to prevent an error during a surgical procedure. 2. The Joint Commission requires two identifiers be utilized prior to administering medications. Most hospitals use the client's date of birth for the second identifier. This is an appropriate action to prevent an error during a medication administration. 3. A quiz during orientation is given to assess whether the new employee understands the information being taught. Giving the answers to the quiz completes the required documentation for the employee's files but does not ensure the new hire understands how to utilize the IV pump. This is a violation of the Patient Safety Goals. 4. Initiating a fall prevention program for an older adult client to prevent falls is an appropriate action to attempt to ensure client safety.

The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.

Correct answer: 3 1. The UAP can apply sequential compression devices to the client on strict bed rest. 2. The UAP can assist with a portable STAT chest x-ray, as long as it is not a female UAP who is pregnant. 3. The client will need to be pre-medicated for a wound debridement; therefore, this task cannot be delegated to the UAP. 4. The UAP can obtain intake and output for clients.

The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? 1. The client diagnosed with flail chest who has just come from the operating room with a right-sided chest tube. 2. The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy. 3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact. 4. The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism.

Correct answer: 3 1. The client who has just returned from surgery should not be transferred from the ICU because he or she may not be stable. 2. A sigmoid colostomy is a surgical procedure that causes major fluid shifts and has the potential for multiple complications; therefore, this client should not be transferred to the surgical unit. 3. Although the client is only 1 day postoperative for a total hip replacement, it is an elective procedure, which indicates that the client was stable prior to the surgery. The incision is also dry and intact. Of the four clients, this client is the most stable and should be transferred to the surgical unit. 4. A fat embolism is a potentially life-threatening complication of a fracture; therefore, this client should not be transferred from the ICU.

The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualified. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

Correct answer: 3 1. The clients would not understand the importance of the specific tasks. Clients will tell the nurse whether the UAP is pleasant when in the room but not whether the delegated tasks have been completed. 2. The nurse retains responsibility for the delegated tasks. The charge nurse may be able to tell the nurse that the UAP has been checked off as being competent to perform the care but would not know whether the care was actually provided. 3. The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care. 4. The nurse would not have time to complete his or her own work if the nurse watched the UAP perform all of the UAP's work.

The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client? 1. To a home healthcare agency. 2. To a senior citizen center. 3. To a rehabilitation facility. 4. To an outpatient physical therapist

Correct answer: 3 1. The home healthcare agency would not be the best referral because comorbid conditions increase the client's recovery time. The client at home does not have access to healthcare 24 hours a day. 2. A senior citizen center may help the client's psychosocial needs but not the client's rehabilitation needs. 3. The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client's recovery. 4. An outpatient physical therapist does not have the education to address and care for the comorbid issues. The physical therapist is focused on the hip fracture only, and the client may have transportation problems going to an outpatient clinic.

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. 2. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. 3. The client with renal calculi who is complaining of severe flank pain and has hematuria. 4. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia.

Correct answer: 3 1. The nurse would expect the client with DIC to be oozing blood; therefore, the nurse should not need to assess this client first. 2. The nurse would expect the client with BPH to have urinary signs and symptoms such as terminal dribbling, so the nurse should not need to assess this client first. 3. The nurse would not expect the client with renal calculi to have blood in the urine (hematuria) and the pain should not be severe; therefore, this client should be assessed to determine if the client is having complications. 4. The nurse would expect the client with Addison's disease to have a bronze pigmentation and hypoglycemia; therefore, the nurse should not need to assess this client first.

The charge nurse must notify a staff member to stay home because of low census. The unit currently has 35 clients who all have at least one IV and multiple IV medications. The unit is staffed with two RNs, three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which nurse should be notified to stay home? 1. The least experienced RN. 2. The most experienced LPN. 3. The UAP who asked to be requested off. 4. The UAP who was hired 4 weeks ago.

Correct answer: 3 1. The registered nurse, experienced or not, can be assigned nursing duties of assessment, planning, teaching, and other duties that cannot be delegated or assigned. The charge nurse has only two RNs for 35 clients. This nurse should not be requested to stay home. 2. An experienced LPN will be needed by the unit to care for the many IV lines and medications. 3. The UAP cannot administer medications or IVs and has requested to be allowed to stay home. This is the best staff member to request to stay home. 4. This UAP may be less experienced on the floor but has not worked long enough to receive any paid time off, and this could greatly affect the UAP's pay.

A major disaster has been called, and the charge nurse on a medical unit must recommend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? 1. The client diagnosed with chronic angina pectoris who has been on new medication for 2 days. 2. The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days. 3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection. 4. The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH, 7.34; PCO2, 55; HCO3, 28; PaO2, 89.

Correct answer: 3 1. This client has been on a medication to control the angina for 2 days and could be discharged. 2. This client is currently completing the amount of care that would be provided in the hospital setting. The client can be taught to continue the Coumadin at home and return to the HCP's office for blood work, or a home health nurse can be assigned to go to the client's home and draw blood for the lab work. 3. Because resistant infections are very difficult to treat, this client should remain in the hospital for the required IVPB medication. 4. These blood gases are expected for a client diagnosed with COPD. This client could go home with oxygen and home health follow-up care.

Which client should the charge nurse of a long-term care facility see first after receiving shift report? 1. The client who is unhappy about being placed in a long-term care facility. 2. The client who wants to have the HCP to order a nightly glass of wine. 3. The client who is upset because the call light was not answered for 30 minutes. 4. The client whose son is being discharged from the hospital after heart surgery.

Correct answer: 3 1. This client will require time to adjust to living in an extended care facility. This would be an expected reaction. 2. This client may or may not be allowed a glass of wine at night. Some long-term care facilities do allow the client to have a controlled amount of alcohol with an HCP order and the family supplying the alcohol, but this client is not priority. 3. This client may or may not have a valid complaint. The nurse should investigate whether or not the complaint is true. Failure to answer a call light can result in the client's attempting to ambulate without assistance and could be a safety issue. The nurse should speak with this client first. 4. The nurse is not in control of the client's son and his discharge, but if the son is being discharged, it can be assumed that the son is in a stable condition, and it is not a priority for the charge nurse to see this client.

The newly admitted client in a long-term care facility stays in the room and refuses to participate in client activities. Which statement is a priority for the nurse to discuss with the client? 1. "You have to get out of this room or you will never make friends here at the home." 2. "It is not so bad living here; you are lucky that we care about what happens to you." 3. "You seem sad; would you like to talk about how you are feeling about being here?" 4. "The activities director can arrange for someone to come and visit you in your room."

Correct answer: 3 1. This may be a true statement, but this client is exhibiting symptoms of depression. The client may or may not wish to make friends at the facility. 2. This is not acknowledging the client's feelings. 3. This client is exhibiting symptoms of depression. Therapeutic conversation is implemented to help the client vent feelings. This statement acknowledges the client's feeling and offers help. 4. This action may get the client to interact with other people, but it does not acknowledge the client's feelings.

The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first? 1. The client who is 4 hours postoperative for abdominal surgery who is complaining of abdominal pain and has hypoactive bowel sounds. 2. The client who is 1 day postoperative for total hip replacement (THR) who has voided 550 mL of clear amber urine in the last 8 hours. 3. The client who is 8 hours postoperative for open cholecystectomy who has a T-tube draining green bile. 4. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot.

Correct answer: 4 1. A client who is 4 hours postoperative for abdominal surgery would be expected to have abdominal pain and hypoactive bowel sounds secondary to general anesthesia. This client would not be assessed first. 2. This output indicates the client is voiding at least 30 mL an hour; therefore, the nurse would not assess this client first. 3. The client with an open cholecystectomy frequently has a T-tube that would normally drain green bile. This client would not be assessed first. 4. The client is exhibiting signs of compromised circulation; therefore, the nurse should assess this client first. The nurse should assess for the 6 Ps: pain, pulse, paresthesia, paralysis, pallor, and polar (cold).

At 0830, the day shift nurse is preparing to administer medications to the client. Which action should the nurse take first? {According to the chart the pt is to receive Lasix and Lanoxin at 0900} 1. Check the client's armband against the medication administration record (MAR). 2. Assess the client's IV site for redness and patency. 3. Ask for the client's date of birth. 4. Determine the client's last K+ level.

Correct answer: 4 1. Checking the client's armband is done prior to actually administering the medications, but it is not the first action for the nurse to take. 2. The nurse should have assessed the client's IV site on first rounds. At this time, all medications to be administered are oral. 3. This is part of the two-identifier system of medication administration implemented to prevent medication errors, but it is not the first action for the nurse to take. 4. The nurse should assess the client's last potassium (K+) level because hypokalemia (abnormally low K+ level) is the most common cause of dysrhythmias in clients receiving digoxin secondary to clients concurrently taking diuretics. Furosemide (Lasix) is a loop diuretic. The nurse should check for digoxin and K+ levels and apical pulse (AP) prior to administering digoxin.{If potassium is low Lasix should not be given. Also, hypokalemia puts the pt at high risk for Digoxin toxicity}

The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing? 1. The client diagnosed with AIDS who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled. 3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

Correct answer: 4 1. Dyspnea and confusion are not expected in a client diagnosed with AIDS; therefore, this client would warrant a more experienced nurse to assess the reason for the complications. 2. The client with financial problems should be assigned to a social worker, not to a nurse. 3. A full-thickness (third-degree) burn is the most serious burn and requires excellent assessment skills to determine whether complications are occurring. This client should be assigned to a more experienced nurse. 4. The client diagnosed with diabetic neuropathy would be expected to have pain; therefore, this client could be assigned to a nurse new to home health nursing. The client is not exhibiting a complication or an unexpected sign/symptom.

The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement? 1. Bathe the client who is incontinent of urine. 2. Document the amount of food the client eats. 3. Conduct the afternoon bingo game in the lobby. 4. Perform routine dressing changes on assigned clients.

Correct answer: 4 1. The LPN can bathe a client, but this should be assigned to the UAP, thereby allowing the LPN to perform a higher-level task. 2. The LPN can document the amount of food the client eats, but this should be assigned to the UAP, thereby allowing the LPN to perform a higher-level task. 3. According to the NCLEX-RN® test plan, collaboration with interdisciplinary team members is part of the management of care. The activity director of the long-term care facility would be responsible for this activity. 4. The LPN's scope of practice allows routine sterile procedures on the client who is stable, such as clients in a surgical rehabilitation facility.

The male client in a long-term care facility complains that the staff does not listen to his complaints unless a family member also complains. Which action should the director of nurses implement? 1. Call a staff meeting and tell the staff to listen to the resident when he talks to them. 2. Determine who neglected to listen to the resident and place the staff member on leave. 3. Ignore the situation because a resident in long-term care cannot determine his needs. 4. Talk with the resident about his concerns and then initiate a plan of action.

Correct answer: 4 1. The director of nurses must first understand the extent of the complaint. Telling staff to ignore preconceived ideas about older adult clients does not work. The director of nurses should have valid information to discuss with the staff. 2. The client has a general complaint, and so more than one staff member may have ignored the client's statements. Neglect was not mentioned in the stem of the question. Not treating the client with the dignity that the client deserves is implied. 3. This is a false statement. Some residents in a long-term care facility may not be able to determine their needs, but this is not true of all residents. 4. The director of nurses should discuss the resident's complaints with the resident and then determine a plan of action to remedy the situation.

The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client's condition. Which information should the nurse discuss with the volunteer? 1. Determine how well she knows the client before talking with the volunteer. 2. Tell the volunteer the client's condition in layperson's terms. 3. Ask the client if it is all right to talk with the volunteer. 4. Explain that client information is on a need-to-know basis only.

Correct answer: 4 1. The fact that the client is a neighbor of the volunteer has no bearing on whether or not the nurse can discuss a client's condition with the volunteer. The nurse should inform the volunteer that information obtained inadvertently is still confidential. 2. The nurse cannot release the client's information in layperson's or medical terms; this is a violation of the Health Insurance Portability and Accountability Act (HIPAA). In many facilities, the client can give a "password" to individuals who can receive information about the client's condition. 3. The nurse should not discuss the situation with the client. This would alert the client to potential breeches in confidentiality. 4. The nurse should remind the volunteer of the HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting.

The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

Correct answer: 4 1. The graduate nurse should handle the situation directly with the UAP first before notifying the charge nurse. 2. This may need to be completed, but not prior to directly discussing the behavior with the UAP. 3. The graduate nurse must address the insubordination with the UAP, not just complete the tasks that are the responsibility of the UAP. 4. The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks

The clinic nurse is reviewing the laboratory data of clients seen in the clinic the previous day. Which client requires immediate intervention by the nurse? 1. The client whose white blood cell (WBC) count is 9.5 mm3. 2. The client whose cholesterol level is 230 mg/dL. 3. The client whose calcium level is 10.4 mg/dL. 4. The client whose International Normalized Ratio (INR) is 3.8.

Correct answer: 4 1. The normal white blood cell count is 5.0 to 10.0 mm3; therefore, this client does not require immediate intervention. 2. The client's cholesterol level is elevated, but this would not require immediate intervention by the nurse. An elevated cholesterol level is not life threatening and can be discussed at the client's next appointment. 3. The client's calcium level is within the normal range of 9.0 to 10.5 mg/dL; therefore, this client does not require an immediate intervention. 4. The therapeutic range for an INR is 2 to 3. This client is at risk for bleeding and requires immediate intervention by the nurse. The nurse should call the client and instruct the client to stop taking warfarin (Coumadin), an anticoagulant.

The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first? 1. Document the findings in the client's chart. 2. Elevate the client's right hand. 3. Assess the radial pulse with the Doppler. 4. Notify the client's healthcare provider.

Correct answer: 4 1. The nurse should always document the findings in the chart, but the first intervention is to get help since the client has neurovascular compromise. 2. Elevating the client's right hand will not help neurovascular compromise. 3. The Doppler can be used to assess the radial pulse, but this client is experiencing neurovascular compromise, which requires immediate medical intervention. 4. The client is exhibiting severe neurovascular compromise, which indicates a surgical complication and requires notifying the surgeon immediately.

The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, "I don't want to go to the nursing home but my son says I have to." Which response would be most appropriate by the nurse? 1. "Let me call a meeting of the healthcare team and your son." 2. "Has the social worker talked to you about this already?" 3. "Why are you so upset about going to the nursing home?" 4. "I can see you are upset. Would you like to talk about it?"

Correct answer: 4 1. The nurse should initiate a client care conference to discuss the client's feelings, but at this time the most appropriate response is to allow the client to begin the grieving process. 2. The nurse could notify the social worker about the client's situation, but the most appropriate response is to allow the client to begin the grieving process, which the client often goes through when experiencing any type of loss. In this situation, the client is losing her independence and her home. 3. The client does not owe the nurse an explanation for "feelings." 4. According to the NCLEX-RN® test plan, advocacy is part of Management of Care under Safe and Effective Care Environment client needs. Therapeutic communication involves being an advocate in this situation, because sometimes the nurse cannot prevent a perceived "bad" situation from occurring.

The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement? 1. Discuss the situation with the client's family. 2. Refer the client to the HH occupational therapist. 3. Request the HH aide to cook all the client's meals. 4. Contact the community's Meals on Wheels.

Correct answer: 4 1. The nurse should not make the client dependent on family members to prepare meals. If the family were willing to do this, they would probably already be doing it. 2. The occupational therapist would teach the client how to cook, but this client is 88 years old and needs meals provided. Therefore, providing meals through Meals on Wheels is the most appropriate intervention. 3. The HH aide's duties do not include cooking all three meals for the client. 4. Meals on Wheels delivers a hot, nutritionally balanced meal once a day on weekdays, usually at noon for older people who do not have assistance in the home for food preparation. This intervention would be most helpful to the client.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction (MI) who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

Correct answer: 4 1. The nurse would expect the client diagnosed with a myocardial infarction to have an elevated troponin level; thus, the nurse would not assess this client first. 2. Because the client's PTT of 68 seconds is 1.5 to 2 times the normal range, it is considered therapeutic and would not warrant the nurse's assessing this client first. 3. The nurse would expect a client with end-stage liver failure to have an elevated ammonia level. 4. The therapeutic range for Dilantin is 10 to 20 mg/dL. This client's higher level warrants intervention because the serum level is above the therapeutic range.

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit. 2. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles. 3. The client diagnosed with bacterial meningitis who has nuchal rigidity and neck pain. 4. The client with Crohn's disease who has right lower abdominal pain and has diarrhea.

Correct answer: 4 1. The nurse would expect the client with an abdominal aortic aneurysm to have an audible bruit; therefore, this client does not warrant immediate intervention. 2. The nurse would expect the client with ARDS to have respiratory signs/symptoms; therefore, this client does not warrant immediate intervention. 3. One of the signs/symptoms of bacterial meningitis is nuchal rigidity; therefore, this client does not warrant immediate intervention. 4. The client with Crohn's disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse. Pain could indicate a complication.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

Correct answer: 4 1. The serum blood glucose level requires a venipuncture, which is not within the scope of the UAP's expertise. The laboratory technician would be responsible for obtaining a venipuncture. 2. This is a sterile dressing change and requires assessing the insertion site for infection; therefore, this would not be the most appropriate task to assign to the LPN. 3. The nurse should ask the UAP to bathe the client and change bed linens because this is a task the UAP can perform. The LPN could be assigned higher-level tasks. 4. The UAP can add up the urine output for the 12-hour shift; however, the nurse is responsible for evaluating whether the urine output is what is expected for the client.

The client in the operating room states, "I don't think I will have this surgery after all." Which intervention should the nurse implement first? 1. Have the surgeon speak with the client. 2. Ask the client to discuss the concerns. 3. Continue to prep the client for surgery. 4. Immediately stop the surgical procedure.

Correct answer: 4 1. This surgeon should speak with the client, but the first intervention is to stop the procedure. 2. Asking the client to discuss concerns should be done, but the first intervention is to stop the procedure. 3. Continuing to prep the client for the surgery can be done, but is inappropriate when the client no longer is giving consent. 4. Stopping the surgical procedure is the first intervention for the nurse to implement.