Delegation/ Prioritization NCLEX

A category 4 hurricane has disrupted a rural, local health care system, creating a significant increase in emergency department admissions. Which client would the nurse anticipate as the priority for intervention? 1. 7 year old with status asthmaticus and an oxygen saturation of 89% 2. 34 year old is 11 weeks pregnant, has gestational diabetes, and has been unable to hold anything down due to nausea and vomiting 3. 45 year old with type 1 diabetes mellitus with blood glucose of 690 mg/dl 4. 55 year old with type 2 diabetes mellitus reporting a headache after being involved in minor motor vehicle accident

1. 7 year old with status asthmaticus and an oxygen saturation of 89% Rationale: A client with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The combination of status asthmaticus and an oxygen saturation ≤92% qualifies for the highest priority level of triage at any age. (Option 3) The 45-year-old client has clinical findings of fatigue, abdominal pain, and a blood glucose level of 690 mg/dL (38.3 mmol/L) that indicate diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment but can be seen after the child with status asthmaticus and impending respiratory deterioration. Severe respiratory instability takes precedence over hemodynamic instability.

The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting? 1. A 2month old who rolled off the changing table and is now lethargic 2. A 3 month old with flat bluish discoloration on the buttock that the mother says has been present since birth 3. A 3 year old with forehead bruises that the mother says resulted from running into a table 4. A 4 year old who pulled boiling water off the stove and has splatter burns on the arms

1. A 2month old who rolled off the changing table and is now lethargic Rationale: Infants begin to roll at age 4-5 months. Reported history that does not match an infant's growth and development is a concern for abuse. Splatter burns, bruises from areas typically hit when falling, and Mongolian spots are expected findings.

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

1. A client post cholecystectomy reporting increased nausea Rationale: Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hostpital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change

1. A client who fell and hit the head but refuses to go to the emergency department 3. A client who needs pre-filled insulin syringes 5. A client with a stage 3 pressure injury in need of a dressing change Rationale: In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. During a weather-related emergency, home care visits are classified as: 1.High priority - unstable clients who need care and are at risk for hospitalization if not seen. 2.Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. 3.Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

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

1. Administering hydromorphone without a prescription 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift Rationale: Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or in violation of nursing law.

The practical nurse is assisting the registered nurse in caring for 4 clients in the pediatric emergency department. Which client should be seen first? 1. Adolescent with abdominal pain, heart rate 120/min and respiration 26/min 2. Child with history of cystic fibrosis has new yellow sputum and cough today 3. Crying infant with fiery redness and moist papules in the diaper region 4. Grade school child with swollen ecchymotic ankle after playing basketball

1. Adolescent with abdominal pain, heart rate 120/min and respiration 26/min Rationale: The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition A pulse of 120/min signals dehydration, and this client's respirations are above normal. This is the most serious acuity. In prioritization, the severity of ABC (airway, breathing, and circulation) is more important than its absolute order. As a result, a severe "C" client comes before a stable "B" client. The priority principle is to save "life before limb." When care must be prioritized, young children do not automatically go first.

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

1. Ask the unlicensed assistive personnel about the situation Because this is not an emergency situation, the nurse should expend sufficient effort to first determine if the test was performed rather than assume it was not. When the completion of an assigned task is questioned, the nurse should first confirm the status of the task with the designated personnel.

The registered nurse delegates actions related to the care of colostomies to the practical nurse. Which actions should the practical nurse question as being outside the licensed practical nurse's scope of practice? Select all that apply. 1. Assessment of the postoperative stoma 2. Client assistance with application pouch 3. Documentation of emptied output 4. Initial client education relating to ostomy care 5. Initial irrigation of postoperative descending colostomy 6. Monitoring ostomy drainage and emptying the pouch

1. Assessment of the postoperative stoma 4. Initial client education relating to ostomy care 5. Initial irrigation of postoperative descending colostomy Rationale: It is within the scope of practice of licensed practical nurses (LPNs) to provide care to clients with established ostomies. Tasks that require assessment, care planning, initial teaching, or care of an unstable client must be performed by the registered nurse (RN). The LPN may assist the client in emptying the pouch, measuring the drainage, and reapplying the pouching system of an established ostomy (Option 2). The LPN may perform the following activities for an established ostomy: -Monitor drainage characteristics (color, amount, odor) (Option 6) -Provide skin care and observe for areas of breakdown around the ostomy -Irrigate the colon of an established ostomy client Provide documentation of observations and interventions (Option 3)

Which tasks can the licensed practical nurse appropriately assign to unlicensed assistive personnel? Select all that apply. 1. Assist the nurse in ambulating a client 1 day post abdominal surgery 2. Measure and empty output into bulb drain 3. Monitor for redness and swelling at a client's IV insertion site 4. Provide extra blankets at the client's request 5. Take family members to the waiting room after a client goes into surgery

1. Assist the nurse in ambulating a client 1 day post abdominal surgery 2. Measure and empty output into bulb drain 4. Provide extra blankets at the client's request 5. Take family members to the waiting room after a client goes into surgery Rationale: Unlicensed assistive personnel may perform noncomplex tasks (eg, escorting family members, providing additional blankets) and clinical tasks (eg, emptying, measuring, and recording output) related to the care of clients under the direction of the licensed practical nurse

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

1. Assist with active and passive range of motion exercises 4. Reapply pneumatic compression device after bathing client 5. Remind the client to use the incentive spirometer Rationale: To prevent immobility hazards for a client in skeletal traction, the nurse can assign the following tasks to unlicensed assistive personnel: -Assist with active and passive range of motion exercises -Notify the nurse of client reports of pain, tingling, or decreased sensation in the affected extremity -Remind the client to use the incentive spirometer -Maintain proper use of pneumatic compression devices (Option 2) UAP change the linens from the top to the bottom of the bed with assistance while clients lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights.

The nurse is working with unlicensed assistive personnel (UAP). Which task can the nurse safely assign to UAP? 1. Assisting a 2 day post op hip arthroplasty client with morning care 2. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter 3. Irrigating colostomy of a 2-day postoperative colostomy client who is stable 4. Refilling the empty eternal feeding container with tube feeding

1. Assisting a 2 day post op hip arthroplasty client with morning care Rationale: Unlicensed assistive personnel (UAP) with the skills and knowledge can perform standardized procedures on stable clients (eg, assisting a client with morning care, emptying a colostomy bag in a client with an established stoma). However, sterile procedures, enteral feedings, or standardized procedures in an unstable client should not be delegated to UAP as these skills require nursing knowledge, judgment, and skill.

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abcess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions

1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing Rationale: Ingestion of antidiabetic drugs (eg, glyburide, glipizide, glimepiride) by a nondiabetic client (eg, child) is an emergency as severe hypoglycemia can result in coma and/or death. Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child.

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

1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg Rationale: Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion. Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas).

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? 1. Client who had a carotid endarterectomy that day with blood pressure of 160/88 mm hg 2. Client who is 1 day post bowel resection with absent bowel sounds 3. Client with a pulse of 109/min who has a history of atrial fibrillation 4. Client with pancreatitis whose total parenteral nutrition is almost finished

1. Client who had a carotid endarterectomy that day with blood pressure of 160/88 mm hg Rationale: A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? 1. Client who had a foot amputation today reporting left shoulder pain radiating down arm 2. Client who has acute pancreatitis reporting severe, continuous penetrating abdominal pain 3. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall 4. Client who has sickle cell disease reporting severe pain in the arms and upper back

1. Client who had a foot amputation today reporting left shoulder pain radiating down arm Rationale: Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction (Option 1).

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with blood pressure of 90/70 mm Hg and deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg 4. Client with pain at the thoracic spine and complete paralysis of both legs

1. Client with blood pressure of 90/70 mm Hg and deviated trachea Rationale: Tension pneumothorax causes marked compression and shifting of mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-threatening emergency. The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures

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

1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse.

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

1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision Rationale: An advance directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. UAP who just received the yearly injectable flu 5. Unlicensed assistive personnel with a cold

1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 4. UAP who just received the yearly injectable flu Rationale: Clients who are immunosuppressed from chemotherapy should not be cared for by a health care provider who is infectious. (Option 1) The medical-surgical nurse has the training to care for a client with immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication. (Option 2) The client is not radioactive or infectious, and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. Option 4) The injectable influenza vaccination does not contain live influenza virus; therefore, the unlicensed assistive personnel is not infectious. The inactivated vaccine is safe and recommended for clients who are immunocompromised

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply. 1. The nurse accepts money from victim 2. The nurse does not accompany the victim on ambulance 3. The nurse does not apply direct pressure to the artery 4. The nurse knows the victim from college 5. The victim dies after reaching the hospital

1. The nurse accepts money from victim 3. The nurse does not apply direct pressure to the artery Rationale: Good Samaritan laws prevent civil action if a nurse stops to assist after an accident, as long as the nurse acts competently, continues care until another appropriate caregiver takes over, and does not accept money.

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1.8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness 2. 11 year old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin

1.8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness Rationale: Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority.

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

4.Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site Rationale: Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis. (Option 1) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. (Option 2) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, Propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection. (Option 3) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This is an expected response to therapy.

The nurse has just received report on 4 clients. Which reported information is the most concerning? 1. Client on a heparin drip with an activated partial thromboplastin time of 60 seconds 2. Client reporting back pain 1 hour following coronary angiography 3. Client with a head injury and a Glasgow Coma Scale score of 14 4. Client with incisional pain rated 6/10 on day 2 post coronary artery bypass graft

2. Client reporting back pain 1 hour following coronary angiography Rationale: Post procedure care of a client who has undergone cardiac catheterization should focus on monitoring hemodynamics (eg, blood pressure, heart rate, strength of distal pulses, temperature of extremities). The client should be also assessed several times per hour (eg, approximately every 15 minutes) for active bleeding or hematoma formation at the incision. Any report of back or flank pain should be investigated for possible retroperitoneal bleeding. Back pain, tachycardia, and hypotension may be the only indications of bleeding as it can take up to 12 hours before a significant drop in hematocrit can be measured. *Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding.

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

2. Client's Glasgow Coma Scale score is 3 4. Client with intracerebral hemorrhage has aphasia Rationale: Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing.

The nurse is assigned to care for four clients. Which client should the nurse see first? 1. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers 2. Female client who had an open reduction and internal fixation of the tibia and reports severe pain and pressure under the cast and inability to move the toes 3. Male client who has two new prosthetic legs applied after traumatic bilateral below the knee amputation and reports crushing pain in the amputated areas 4. Male client who has a hematocrit of 37% and hemoglobin of 12.5 g/dl and is prescribed enoxaparin 1 day after a total hip arthroplasty

2. Female client who had an open reduction and internal fixation of the tibia and reports severe pain and pressure under the cast and inability to move the toes Rationale: Compartment syndrome is a condition of impaired circulation due to increased tissue pressure, often from edema or medical devices. Clients with signs of compartment syndrome (eg, severe, unrelenting pain; paralysis) require immediate assessment and intervention to prevent permanent tissue damage or loss of limb. (Option 1) Edema and numbness or tingling (paresthesia) of the hands and fingers commonly occur from inappropriate sling application. Numbness and tingling also are early signs of compartment syndrome. However, the client with late signs of compartment syndrome (eg, paralysis) should be seen first. (Option 3) Clients with amputations may experience phantom limb pain that is severe and described as burning or crushing and requires pain management. However, limb-threatening emergencies should be managed first. (Option 4) Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50%, 13.2-17.3 g/dL, respectively) are expected after hip arthroplasty due to intra- and postoperative blood loss.

A client with terminal cancer becomes hypoxic and unresponsive. According to the client's paperwork, the client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes 2. Get directions about care from the client's sister 3.Prepare for emergency intubation 4. Request that the sister provide a living will

2. Get directions about care from the client's sister Rationale: Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who will advocate on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual becomes the final decision maker.

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

2. Health care proxy 4. Living will Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is unable to do so. Advanced directives are legal documents outlining these wishes and include living wills and health care proxies (durable powers of attorney for health care or medical power or attorney).

The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel? 1. Call the family to give an update on new aspects of the client's condition 2. Lower the temperature in the room to make the environment cooler 3. Reinforce teaching about signs and symptoms of hyperthyroidism 4. Take vital signs and place a warming blanket on the client

2. Lower the temperature in the room to make the environment cooler Rationale: Thyrotoxicosis, or thyroid storm, is a complication of hyperthyroidism that occurs when excessive amounts of thyroid hormone are released into the circulation. Manifestations include tachycardia and hyperthermia. Keeping the client and room temperature cool is a therapeutic action that the nurse can delegate to unlicensed assistive personnel (UAP).

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

2. Nonmaleficence Rationale: Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their clients.

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

2. Perform range of motion exercises 3. Reapply the restraints after toileting 4. Report changes in skin integrity 5. Turn and reposition the client in bed Members of the health care team providing direct care for clients in physical restraints are required to complete an educational training program and demonstrate competency in caring for a client in restraints. Therefore, the nurse can safely assign the following tasks to unlicensed assistive personnel: performing range of motion exercises, reapplying restraints, repositioning a restrained client in bed, and immediately reporting changes observed in the skin or any other problems.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply. 1. Educate newly admitted client on the importance of using the call light for assistance 2. Place the bedside commode as close to the bad as possible 3. Remind client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker

2. Place the bedside commode as close to the bad as possible 3. Remind client to change position slowly 4. Report observations of changes in client's condition immediately Rationale: -Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible (Option 2). -Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Option 3). -Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately (Option 4). Most client falls are unobserved and occur in the client's room or bathroom. Assessment, evaluation, client orientation, and teaching are not appropriate to delegate to unlicensed assistive personnel.

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

3. 78 year old prescribed warfarin who reports imcreasing headaches and gait disturbance after falling a month ago Rationale: Elderly clients and individuals taking anticoagulants are especially vulnerable to developing a chronic subdural hematoma. Manifestations of the condition (eg, headache, gait disturbance, memory loss, confusion) should be investigated immediately as this neurologic emergency can lead to increased intracranial pressure and death.

The nurse recognizes which factor as possibly contributing to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L 3. Administered warfarin to a client with International Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

3. Administered warfarin to a client with International Normalized Ratio of 6 Rationale: The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is >4. Warfarin is an anticoagulant often used in clients with the following: -Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) -Deep venous thrombosis and pulmonary embolism (to prevent additional clots) -Mechanical heart valves (to prevent clot formation on valves)

Which tasks are appropriate for the nurse in a long-term care unit to delegate to unlicensed assistive personnel? Select all that apply. 1. Assign lunch times to other UAP on the unit 2. Assist a client with bathing and changing an ostomy appliance 3. Collect vital signs on a client newly arrived on the unit 4. Pick up a prescribed oral antibiotic from the pharmacy 5. Record intake and output for a client with chronic neurogenic bladder

3. Collect vital signs on a client newly arrived on the unit 4. Pick up a prescribed oral antibiotic from the pharmacy 5. Record intake and output for a client with chronic neurogenic bladder Rationale: Client care that is specific to the nursing process (assessment, monitoring, assisting in planning, evaluation) cannot be delegated to unlicensed assistive personnel (UAP). UAP can assist with basic care activities, check routine vital signs, document intake and output, and assist with activities of daily living, hygiene, and positioning for stable clients. The nurse is ultimately accountable for the care provided by UAP.

Which task would the practical nurse on a surgical unit assign to experienced unlicensed assistive personnel? 1. Assisting a client in ambulating to the bathroom for the first time following surgey 2. Explaining why incentive spirometer use is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar level of 70 mg/dl 4. Taking vital signs every 15 minutes on a client who was just transferred from the post anesthesia recovery unit

3. Feeding a client with dementia who has a blood sugar level of 70 mg/dl The PN appropriately assigns the routine task of feeding to the UAP. The general procedure and safety principles associated with feeding (positioning, observing swallowing, recording intake) do not change because of the client's diagnosis of dementia. In addition, normal fasting blood glucose levels are 70-110 mg/dL The practical nurse (PN) can assign routine tasks such as taking vital signs, supervising ambulation, making beds, and assisting with hygiene and activities of daily living to experienced unlicensed assistive personnel. Data collection, planning, implementation, and evaluation are the responsibilities of the PN.

The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? 1. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation 2. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. HCP notified 3. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will continue to monitor for swelling and pain every hour. 4. Package of green leaves found in client drawer at 1:00 pm. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings

3. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will continue to monitor for swelling and pain every hour. Rationale: After an adverse event, the nurse should document objective, specific assessments and interventions. These include signs/symptoms indicating a lack of client harm and any corrective actions taken.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, " I'm in pain". Medication provided 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x1

3. Inspiratory wheezes heard in bilateral lower lung fields Rationale: Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

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

3. Male client with an open bowel resection with a Foley catheter Rationale: Nurses who are floated for a shift to areas different than their usual client population should be assigned clients who can be managed using skills similar to those used for their usual client population and not requiring specialized knowledge. An abdominal bowel surgery with a Foley catheter is similar to the type of care required with a cesarean section; therefore, this client should be assigned to the obstetrical (OB) nurse. -Floating nurses should be assigned clients who require care that can be given using skills and knowledge similar to those used for their usual client population. Obstetrical nurses should not be assigned infectious clients.

The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply. 1. Administering oral pain medication if client reports low back pain 2. Checking for bleeding at catheter insertion site every 15 minutes 3. Performing post-procedure vital sign measure 4. Reinforcing instructions to keep the involved extremity straight 5. Reviewing ECG for dysrhythmias

3. Performing post-procedure vital sign measure 5. Reviewing ECG for dysrhythmias Rationale: In the client who has had a percutaneous coronary intervention, after the initial assessment and its comparison to pre-procedure baseline, the registered nurse may assign the following tasks to the practical nurse: medication administration, monitoring of neurovascular status of the involved extremity, checking for bleeding at the catheter insertion site, and reinforcing important teaching.

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

3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room Rationale: Experienced unlicensed assistive personnel can post signs on the client's door that display airborne isolation precautions, stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room. The nurse is responsible for appropriate communication with other departments and reinforcement of instructions to clients and their families.

Unlicensed assistive personnel report 4 situations to the nurse. Which situation warrants the nurse's intervention first? 1. ROOM 1: Client on a 24 hour urine collection had a specimen discarded by mistake 2. ROOM 2: Client and family request clergy to administer last rites 3. ROOM 3: Puncture-resistant sharps disposal container on the wall is full 4. ROOM 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dl

3. ROOM 3: Puncture-resistant sharps disposal container on the wall is full Rationale: Prevention of injury and safety in the workplace should be a priority when the nurse is delegating, planning, or providing nursing care. (Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required. (Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.

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

3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it Rationale: Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Assault is the threat of battery.

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

3. Type 1 diabetes mellitus with blood glucose of 55 mg/dl Rationale: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia. Clients respond rapidly to nursing intervention (eg, sugar tablets, orange juice).

The licensed practical nurse (LPN) rounds on four clients. Which finding is the priority for the LPN to report to the registered nurse? 1.Client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg 2. Client with pneumonia with a temperature of 101.8 F and unable to recieve antibiotics due to occluded IV catheter 3. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour 4. Client with type 2 diabetes whose fingerstick glucose level is 220 md/dl

3.Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour Rationale: Severe, acute pain in clients with sickle cell disease is a common indicator of vasoocclusion and tissue ischemia from a sickle cell crisis. The nurse should immediately report signs of sickle cell crisis so that interventions may be implemented to prevent irreversible tissue damage (eg, myocardial infarction) and death. (Option 1) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia also may occur normally in clients with hyperthyroidism and is less concerning in the presence of other normal vital signs. This client requires further assessment once ischemic events are prevented. (Options 2 and 4) Administration of antibiotics and correction of hyperglycemia can be safely addressed after resolving potentially life-threatening complications.

The nurse receives report on 4 clients. Which client should be seen first? 1. 10 month old with audible congestion and mucus-producing cough 2. 10 year old with active nose bleed who is applying pressure 3. 12 year old with urinary frequency and burning , and fever 4. 15 year old with painful right hip. fever, and limited range of motion

4. 15 year old with painful right hip. fever, and limited range of motion Rationale: This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

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

4. The health care proxy The role of the health care proxy is to make decisions for a client who is unable to do so. Ideally, the proxy will have a good understanding of the client's wishes and will be emotionally capable of fulfilling this important role.

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2 year old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2. 4 year old post adenotonsillectomy who is now reporting ear pain 3. 6 year old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4. 7 year old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

4. 7 year old 5 days post tonsillectomy who wants to return to soccer practice tomorrow Rationale: The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first? 1. Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding 2. Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding 3. Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have bowel movement 4. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F

4. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F Rationale: Postoperative infection of an arteriovenous graft may result in thrombosis (clotting), graft failure, or systemic infection. The nurse should immediately assess the client with signs of postoperative infection (eg, fever) and notify the health care provider. Arteriovenous (AV) graft placement involves surgical connection of an artery to a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection usually manifests approximately 3-5 days after surgery

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

4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting Rationale: An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. (Option 1) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary. (Option 2) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia). Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel. (Option 3) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are expected in a client with an infected venous leg ulcer.

The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Direct the client's primary nurse to examine the client 4. Personally go and ausculate the client's lungs

4. Personally go and ausculate the client's lungs When a nurse receives report from unlicensed assistive personnel (UAP) of a client symptom that is potentially ominous, the nurse should personally assess the client. This is the primary nursing assessment that will be used to decide if an urgent need exists that requires intervention.

The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate? 1. I need you to take vital signs on all clients in rooms 1-10 this morning 2. Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely 3. Please ensure that Mr. Garcia in room 8 ambulates several times 4. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100

4. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100 Rationale: Nurses assigning client care to unlicensed assistive personnel must consider the five rights of delegation. Right direction/communication involves providing clear instructions about the assigned tasks, specific information needed for task completion, the time frame, and when to report back to the nurse.

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

4. Refer employee to the employee's health care provider Rationale: The nurse should not give medication to an employee without a prescription, even if it is an over-the-counter drug, as a legal caregiving relationship will be established by doing so. The employee should be referred to the employee's health care provider.

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

4. Request that the spouse tell the client to call back Rationale: A competent adult with decision-making capacity can refuse essential treatment; the client's spouse does not have that legal authority. Treatment refusal must include awareness of the risks and benefits

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

4.There are many types of POAs. Let's clarify if your POA can make health care decisions for you Rationale: An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power of attorney (POA) designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care [Canada]).

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. 1. Client develops right-sided upper a lower extremity drift 2. Client found lying unconscious on floor 3. Client has order for heparin with surgery planned for the morning 4. Client refuses a prescribed routine pain meds

Back Front 1. Client develops right-sided upper a lower extremity drift 2. Client found lying unconscious on floor 3. Client has order for heparin with surgery planned for the morning Rationale: The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: -Falls -Deteriorates significantly or dies -Has critical laboratory results -Needs a prescription that requires clarification -Leaves against medical advice or runs away -Refuses key treatments in a relevant period -Administration of heparin is normally discontinued prior to surgery due to the increased risk of bleeding and should be clarified with the HCP (Option 3). A serum sodium of 124 mEq/L (124 mmol/L) (normal: 135-145 [135-145]) represents a critical value that can lead to altered mental status and seizures (Option 4)

Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

Experienced UAP can assist stable clients with activities of daily living, hygiene needs, ambulation, transfer, and repositioning. They can also take vital signs (eg, pulse oximetry), assist with treatments, and prevent aspiration (eg, repositioning). However, the PN is responsible for ensuring the client's safety, supervision of the UAP, and evaluation of the care rendered by the UAP

HIPPA

Health Insurance Portability and Accountability Act requirements related to privileged health information include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes.