PDM: Chapter 6

Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse? 1. The LPN has the trough drawn after hanging the aminoglycoside. 2. The LPN changes out a "sharps" container that is over the fill line. 3. The LPN asks another nurse to observe wastage of a narcotic. 4. The LPN inserts an indwelling urinary catheter into the client.

1. The LPN has the trough drawn after hanging the aminoglycoside.

The nurse is observing the unlicensed assistive personnel (UAP) provide care to a client with an indwelling catheter. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP does not secure the tubing to the client's leg with tape. 2. The UAP wears gloves when providing catheter care to the client. 3. The UAP positions the collection bag on the side of the client's bed. 4. The UAP cares for the client's catheter after washing his or her hands.

1. The UAP does not secure the tubing to the client's leg with tape.

The client is 1 day postoperative transurethral resection of the prostate (TURP). Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP increased the client's irrigation fluid to clear clots from the tubing. 2. The UAP elevated the client's scrotum on a towel roll for support. 3. The UAP emptied the client's indwelling urinary catheter bag. 4. The UAP brought ice water to the client's bedside.

1. The UAP increased the client's irrigation fluid to clear clots from the tubing.

The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation? 1. The client with a cystectomy who had a creation of an ileal conduit. 2. The client on continuous hemodialysis who is awaiting a kidney transplant. 3. The client with renal trauma secondary to a motor vehicle accident. 4. The client who has had abdominal surgery and whose wound has eviscerated.

1. The client with a cystectomy who had a creation of an ileal conduit.

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92. 2. The client on peritoneal dialysis who has a clear dialysate draining from the abdomen. 3. The client on hemodialysis whose right upper arm fistula has an audible bruit. 4. The client diagnosed with cystitis who is complaining of burning on urination.

1. The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92.

The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first? 1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale. 2. The aminoglycoside antibiotic vancomycin intravenous piggyback (IVPB) to the client with an infected abdominal wound. 3. The proton-pump inhibitor pantoprazole (Protonix) IVPB to the client who is at risk for developing a stress ulcer. 4. The loop-diuretic furosemide (Lasix) intravenous push (IVP) to the client who has undergone surgical debridement of the right lower limb.

1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale.

The home health (HH) aide tells the home health nurse one of the older male clients is taking an herbal supplement, saw palmetto, every day. Which statement is the nurse's best response? 1. "Herbal supplements are dangerous and I will talk to the client." 2. "Saw palmetto is used to treat benign prostatic hypertrophy. Let him take it." 3. "I will notify the client's healthcare provider as soon as possible." 4. "Many clients use herbal supplements. He has a right to take it."

2. "Saw palmetto is used to treat benign prostatic hypertrophy. Let him take it."

The 18-year-old client diagnosed with renal trauma is admitted to the critical care unit after a serious motor vehicle accident resulting from driving under the influence. The mother comes to the unit and starts yelling at her son about "driving drunk." Which action should the nurse implement? 1. Allow the mother to continue talking to her son. 2. Notify the hospital security to remove the mother. 3. Escort the mother to a private area and talk to her. 4. Tell the mother if she wants to stay, she must be quiet.

3. Escort the mother to a private area and talk to her.

. Which task should the employee health nurse delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP read the PPD result administered to the client 72 hours ago. 2. Ask the UAP to obtain a urine specimen for the client having a urine drug screening. 3. Tell the UAP to apply an ice pack to the client who slipped and has a sprained right ankle. 4. Instruct the UAP to complete the incident report for the nurse who had a "dirty needle stick."

3. Tell the UAP to apply an ice pack to the client who slipped and has a sprained right ankle.

The client scheduled for a D&C is upset because the HCP told her she has syphilis. The client asks the nurse, "This is so embarrassing. Do you have to tell anyone about this?" Which statement is the nurse's best response? 1. "This must be reported to the Public Health Department and your sexual partners." 2. "According to the Health Insurance Portability and Accountability Act (HIPAA), I cannot report this to anyone without your permission." 3. "You really should tell your sexual partners, so they can be treated for syphilis." 4. "I realize you are embarrassed. Would you like to talk about the situation?"

1. "This must be reported to the Public Health Department and your sexual partners."

Which task is most appropriate for the nurse on the renal unit to delegate to the unlicensed assistive personnel (UAP)? 1. Escort the client with acute polynephritis to the radiology department for a CT scan. 2. Obtain a sterile urine specimen for the client to rule out (R/O) a urinary tract infection. 3. Hang the bag of D5W for the client diagnosed with post-streptococcal glomerulonephritis. 4. Provide discharge instructions for the client diagnosed for nephrotic syndrome.

1. Escort the client with acute polynephritis to the radiology department for a CT scan.

Which nursing task should the nurse on the renal unit assign to the licensed practical nurse (LPN)? 1. Insert an indwelling urinary catheter before surgery. 2. Turn and reposition the client every 2 hours. 3. Measure and record the urine in the bedside commode. 4. Feed the client who choked on food during the last meal.

1. Insert an indwelling urinary catheter before surgery.

The nurse is caring for clients on the renal unit. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to calculate the clients' urinary intake and output. 2. Request the UAP to double-check a unit of blood that is being administered. 3. Tell the UAP to change the surgical dressing on the client with a kidney transplant. 4. Ask the UAP to transfer the client from the renal unit to the intensive care unit.

1. Instruct the UAP to calculate the clients' urinary intake and output.

The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation, it is edematous, and a red streak has formed. Which interventions should the nurse implement? Rank in priority order. 1. Start a new IV in the right hand. 2. Discontinue the intravenous line. 3. Complete an incident record. 4. Place a warm washcloth over the site. 5. Document the situation in the client's chart.

2, 1, 4, 5, 3

The 78-year-old client with Alport syndrome asks the clinic nurse, "What should I do so I won't get sick this winter?" Which priority statement is the nurse's best response? 1. "You should not be around any crowds during the winter months." 2. "It is recommended you get a flu vaccine yearly." 3. "You need to eat three well-balanced meals a day." 4. "Dress warmly when it is less than 40 degrees Fahrenheit outside."

2. "It is recommended you get a flu vaccine yearly."

The male client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Request the client to urinate in a urinal. 2. Assess the client's pain. 3. Increase the client's oral fluid intake. 4. Strain the client's urine

2. Assess the client's pain.

The hospice nurse is providing follow-up care with the family member of a client who died with chronic renal disease. Which intervention is priority? 1. Attend the client's funeral service or visitation. 2. Check on the family 1 to 2 months after the death of the client. 3. Make sure the arrangements are what the client wanted. 4. Help the family member dispose of the client's belongings as soon as possible.

2. Check on the family 1 to 2 months after the death of the client.

The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first? 1. Ask the client if he has any prostate problems. 2. Determine if the client has any betadine allergies. 3. Lubricate the end of the indwelling catheter. 4. Ensure urine is obtained in the indwelling catheter.

2. Determine if the client has any betadine allergies.

The nurse is working at the emergency health clinic in a disaster shelter. Which intervention is priority when initially assessing the client? 1. Find out how long the client will be in the shelter. 2. Determine whether the client has his or her routine medications. 3. Document the client's health history in writing. 4. Assess the client's vital signs, height, and weight.

2. Determine whether the client has his or her routine medications.

The nurse is attempting to start an intravenous (IV) line in an elderly client who is dehydrated. After two unsuccessful attempts, which intervention should the nurse implement? 1. Keep trying to get a patent IV access. 2. Ask the HCP to order oral fluid replacement. 3. Ask a second nurse to attempt to start the IV. 4. Place cold packs on the client's arms for comfort.

3. Ask a second nurse to attempt to start the IV.

The employee health nurse is obtaining a urine specimen for a pre-employment drug screen. Which action should the nurse implement first? 1. Obtain informed consent for the procedure. 2. Maintain the chain of custody for the specimen. 3. Allow the client to go to any bathroom in the clinic. 4. Take and record the client's tympanic temperature.

2. Maintain the chain of custody for the specimen.

The nurse observes an LPN discussing an intravenous pyleogram, a diagnostic test, with a client in the waiting room of the outpatient clinic. Which action should the nurse implement? 1. Praise the LPN for talking to the client about the diagnostic test. 2. Tell the LPN the nurse needs to talk to her in the office area. 3. Go to the waiting room and tell the LPN not to discuss this there. 4. Inform the HCP that the LPN was talking to the client in the waiting room.

2. Tell the LPN the nurse needs to talk to her in the office area.

The nurse is caring for an elderly female client who has an indwelling catheter. Which data warrants notifying the healthcare provider? 1. The client's vital signs are T 98, AP 90, RR 16, B/P 142/88. 2. The client has had a change in her mental status. 3. The client's urine is cloudy with sediment. 4. The client has no discomfort or pain.

2. The client has had a change in her mental status.

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with acute glomerulonephritis who has oliguria and periorbital edema. 2. The client with benign prostatic hypertrophy who has blood oozing from the intravenous site. 3. The client with renal calculi who is complaining of flank pain rated as a 5 on a scale of 1 to 10. 4. The client with nephrotic syndrome who has proteinuria and hypoalbuminemia.

2. The client with benign prostatic hypertrophy who has blood oozing from the intravenous site.

The female client with renal calculi is scheduled for a STAT kidney, ureter, bladder (KUB). Which statement by the client warrants intervention by the nurse? 1. "I am allergic to shell fish and iodine." 2. "I just had my lunch tray and ate all of it." 3. "I have not had my period for 3 months." 4. "I am having pain in my lower back."

3. "I have not had my period for 3 months."

The unlicensed assistive personnel (UAP) reports to the nurse the client's urine output has bright red blood. Which intervention should the nurse implement first? 1. Instruct the UAP to take a urine specimen to the laboratory. 2. Document the findings in the client's nursing notes. 3. Assess the client's urine specimen and complete a renal assessment. 4. Ask the UAP to take the client's vital signs.

3. Assess the client's urine specimen and complete a renal assessment.

The UAP in the school nurse's office is listening to a female student who is pregnant and scared to tell her parents. Which action should the school nurse implement? 1. Tell the UAP she cannot talk to the female student. 2. Call the student's parents and tell them their daughter is pregnant. 3. Do not take any action and allow the UAP to listen to the student. 4. Ask the UAP to leave and continue to talk to the student.

3. Do not take any action and allow the UAP to listen to the student.

The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Tell the UAP to check the amount, color, and consistency of the client's urine output. 2. Request the UAP to transcribe the client's healthcare provider's orders. 3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container. 4. Ask the UAP to take the client's post-procedural vital signs.

3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container.

The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform? 1. Measure the client's output from the indwelling catheter. 2. Record the client's intake and output on the I&O sheet. 3. Instruct the client on appropriate fluid restrictions. 4. Provide water for a client diagnosed with acute polynephritis.

3. Instruct the client on appropriate fluid restrictions.

The client with open surgery of the kidney has an AP 118 and B/P 88/58. Which intervention should the nurse implement first? 1. Obtain the client's pulse oximeter reading. 2. Check the client's last hemoglobin and hematocrit. 3. Notify the client's surgeon immediately. 4. Monitor the client's urine output.

3. Notify the client's surgeon immediately.

The HCP orders an intravenous pyelogram for the 27-year-old male client diagnosed with R/O renal calculi. The client is diagnosed with schizophrenia and is delusional. Which action should the clinic nurse implement? 1. Ask the client whether he is allergic to yeast. 2. Request the client to sign a permit for the procedure. 3. Obtain informed consent from the client's significant other. 4. Discuss the local hospital's day surgery procedure with the client.

3. Obtain informed consent from the client's significant other.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Keep the client NPO during the time the urine is being collected. 2. Instruct the client to urinate, and include this urine when starting collection. 3. Place client's urine in an appropriate specimen container for 24 hours. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Post signs on the client's door alerting staff to save all of the client's urine output.

3. Place client's urine in an appropriate specimen container for 24 hours. 5. Post signs on the client's door alerting staff to save all of the client's urine output.

The nurse is preparing to perform a dressing change on a female client who has end-stage renal disease. The nurse notes the client's husband is silently holding the client's hand and praying. Which action should the nurse implement first? 1. Continue to prepare for the dressing change in the room. 2. Call the chaplain to help the client and spouse pray. 3. Quietly leave the room and come back later for the dressing change. 4. Ask the husband whether or not he would like the nurse to join in the prayer.

3. Quietly leave the room and come back later for the dressing change.

The male client with chronic kidney disease has received the initial dose of erythropoietin, a biological response modifier, 1 week ago. Which data warrants the nurse to notify the healthcare provider? 1. The client's pulse oximeter reading of 95%. 2. The client has a platelet count of 155,000. 3. The client has a blood pressure reading of 184/102. 4. The client has a tympanic temperature of 99.8°F.

3. The client has a blood pressure reading of 184/102.

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. 1. Place the client's TPN on a gravity intravenous line. 2. Monitor the client's blood glucose every 24 hours. 3. Weigh the client daily, first thing in the morning. 4. Change the client's IV tubing with every TPN bag administered. 5. Monitor the client's intake and output every shift.

3. Weigh the client daily, first thing in the morning. 4. Change the client's IV tubing with every TPN bag administered. 5. Monitor the client's intake and output every shift.

The 88-year-old female client is complaining of urinary frequency and dribbling. Which nursing interventions should be implemented? Rank in order of performance. 1. Have the unlicensed assistive personnel (UAP) make "potty" rounds on the client every 2 hours. 2. Give the client perineal pads to place inside her underwear. 3. Place an absorbent pad on the client's bed. 4. Put a bedside commode at the client's bedside. 5. Instruct the client in providing a clean-catch urine specimen.

4, 5, 2, 3, 1

The nurse is preparing to administer medications. Which medication should the nurse administer first? 1. Digoxin (Lanoxin), a cardiac glycoside, due at 0900. 2. Furosemide (Lasix), a loop diuretic, due at 0800. 3. Propoxyphene (Darvon), an analgesic, due in 2 hours. 4. Acetaminophen (Tylenol), an analgesic, due in 5 minutes.

4. Acetaminophen (Tylenol), an analgesic, due in 5 minutes.

The nurse is preparing to administer intravenous narcotic medication to the client who has renal calculi and is complaining of pain rated as 8 on 1 to 10 pain scale. The client's vital signs are stable. Which intervention should the nurse implement first? 1. Clamp the IV tubing proximal to the port of medication administration. 2. Administer the narcotic medication slowly over 2 minutes. 3. Check the medication administration record (MAR) against the hospital identification band. 4. Determine if the client's intravenous site is patent.

4. Determine if the client's intravenous site is patent.

The nurse is developing a nursing care plan for the client diagnosed with chronic kidney disease. Which nursing problem should be addressed first? 1. Self-care deficit. 2. Knowledge deficit. 3. Chronic pain. 4. Excess fluid volume.

4. Excess fluid volume.

The elderly female client diagnosed with osteoporosis is prescribed the bisphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication? 1. Administer the medication first thing in the morning. 2. Ask the client whether she has a history of peptic ulcer disease. 3. Encourage the client to walk for at least 30 minutes. 4. Have the client remain upright for 30 minutes after administering the medication.

4. Have the client remain upright for 30 minutes after administering the medication.

Which nursing diagnosis is priority for the client who has undergone a transurethral resection of the prostate (TURP)? 1. Potential for sexual dysfunction. 2. Potential for altered urinary elimination. 3. Potential for infection. 4. Potential for hemorrhage.

4. Potential for hemorrhage.

The nurse and unlicensed assistive personnel (UAP) are working in a family practice clinic. Which task should the nurse delegate to the UAP? 1. Give the client sample medications for a urinary tract infection (UTI). 2. Show the client how to use a self-monitoring blood glucometer. 3. Answer the telephone triage line and take messages from clients. 4. Take the vital signs of a client scheduled for a physical examination.

4. Take the vital signs of a client scheduled for a physical examination.

The unit manager on the renal unit is evaluating the staff nurse. Which data should be included in the nurse's yearly evaluation? 1. The fact that the nurse clocked in late to work twice in the last year. 2. The complaint stating the nurse did not answer a call light during a code. 3. The number of times the nurse switched shifts with another nurse. 4. The appropriateness of the nurse's written documentation in the charts.

4. The appropriateness of the nurse's written documentation in the charts.

The nurse is caring for clients on a renal unit and making assignments for the day shift. Which client should the nurse assess first? 1. The client diagnosed with interstitial cystitis who has urinary urgency and pain in the bladder. 2. The client with acute post-streptococcal glomerulonephritis who has hematuria with a smoky appearance. 3. The client diagnosed with Goodpasture syndrome who has pallor, anemia, and renal failure. 4. The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain, rating it as a 9 on 1 to a 10 pain scale.

4. The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain, rating it as a 9 on 1 to a 10 pain scale.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has a hemoglobin of 9.0 mg/dL and hematocrit of 26%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is reporting a 3.6 kg weight gain and is refusing dialysis. 4. The client on peritoneal dialysis who is complaining of a hard, rigid abdomen.

4. The client on peritoneal dialysis who is complaining of a hard, rigid abdomen.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? 1. The client diagnosed with polycystic kidney disease who has a B/P 170/100. 2. The client diagnosed with bladder cancer who has gross painless hematuria. 3. The client diagnosed with renal calculi who thinks he passed a stone. 4. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.

4. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.

The elderly patient diagnosed with heart failure is scheduled to receive a unit of packed red blood cells (PRBCs). The PRBCs are prepared in 350 mL of solution. At what rate should the nurse set the pump?

88 mL/hr

Which behavior warrants intervention by the clinical manager in the medical-surgical outpatient clinic? 1. The UAP is discussing a client's condition in the waiting room. 2. The LPN is talking to a client over the phone about laboratory tests. 3. The RN is triaging phone messages during his or her lunch break. 4. The UAP is taking vital signs for the client being placed in a room.

1. The UAP is discussing a client's condition in the waiting room.

The client had surgery to remove a kidney stone. Which of the following laboratory assessment data warrants intervention by the nurse? 1. A serum potassium level of 5.2 mEq/L. 2. A urinalysis showing blood in the urine. 3. A creatinine level of 1.2 mg/100 mL. 4. A white blood cell count of 9,500 mm/dL.

2. A urinalysis showing blood in the urine.

The charge nurse is making shift assignments to the surgical staff, which consists of two nurses, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAP). Which assignment would be most appropriate for the charge nurse to make? 1. Instruct the nurse to administer all PRN medications. 2. Instruct the UAP to clean the recently vacated room. 3. Assign the LPN to change the client's ileal conduit bag. 4. Request the LPN to complete the admission for a new client.

3. Assign the LPN to change the client's ileal conduit bag.

The client with chronic kidney disease is placed on a fluid restriction of 1,500 milliliters per day. On the 7 a.m. to 7 p.m. shift the client drank an 8-ounce cup of coffee, 8 ounces of juice, 16 ounces of tea, and 8 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?

300 mL

The nurse emptied 2,340 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the hanging bag was 3,000 mL at the beginning of the shift. There was 1,550 mL left in the bag 8 hours later. What is the correct urine output at the end of the 8 hours?

890 mL

The nurse manager in the medical-surgical outpatient clinic is making assignments. Which task is most appropriate to delegate/assign to the UAP/LPN? 1. Ask the LPN to administer the flu vaccine to the client. 2. Tell the UAP to call the pharmacist to refill a prescription. 3. Request the LPN to obtain the height and weight of the client. 4. Instruct the UAP to empty the trashcans in the clients' rooms.

1. Ask the LPN to administer the flu vaccine to the client.

The client receiving dialysis is complaining of being dizzy and light-headed. Which priority intervention should the nurse implement? 1. Place the client in the reverse Trendelenburg position. 2. Decrease the volume of blood being removed from the client. 3. Bolus the client 300 mL of 0.9% saline solution. 4. Notify the healthcare provider as soon as possible.

3. Bolus the client 300 mL of 0.9% saline solution.

The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, "I am taking saw palmetto for my enlarged prostate." Which intervention should the nurse implement first? 1. Notify the client's HCP to write an order for the herbal supplement. 2. Ask the client why he is taking an herb for his enlarged prostate. 3. Consult with the pharmacist to determine any potential drug interactions. 4. Look up saw palmetto in the Physicians' Desk Reference (PDR).

3. Consult with the pharmacist to determine any potential drug interactions.

The home health (HH) nurse is admitting a female client diagnosed with end-stage renal disease who refuses to be placed on hemodialysis. The client is ready to die, but verbalizes having so many regrets in her life. Which intervention would be most appropriate for the nurse? 1. Contact the agency chaplain to come talk to the client. 2. Call her church pastor and discuss the client's concerns. 3. Ask the client whether or not she would like to pray with the nurse. 4. Determine whether or not the client has an advance directive.

1. Contact the agency chaplain to come talk to the client.

Which intervention should the nurse implement first for the client diagnosed with urinary incontinence? 1. Palpate the bladder after an incontinent episode. 2. Administer oxybutynin, an anticholinergic agent. 3. Ensure the client does not sit or lie in the urine. 4. Instruct the client to go to the bathroom every 2 hours.

1. Palpate the bladder after an incontinent episode.

Which intervention should the nurse implement first when assisting a client with a flaccid bladder to urinate? 1. Perform the Credé's maneuver on the client. 2. Perform intermittent catheterization on the client. 3. Place the client on the bedside commode. 4. Request the client to drink a full glass of water.

1. Perform the Credé's maneuver on the client.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The 24-year-old client who had a circumcision and is being prepared for discharge. 2. The client scheduled for a cystectomy who is crying and upset about the surgery. 3. The client diagnosed with kidney cancer who is receiving two units of blood. 4. The client who has end-stage renal disease and had an arteriovenous fistula created.

1. The 24-year-old client who had a circumcision and is being prepared for discharge.

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? 1. The UAP empties the indwelling catheter bag for the client with transurethral resection of the prostate (TURP). 2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall. 3. The UAP provides apple juice to the client with a nephrectomy who has just been advanced to a clear liquid diet. 4. The UAP applies moisture barrier cream to the elderly client with urinary incontinence who has an excoriated perianal area.

2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall.

The client diagnosed with chronic kidney disease (CKD), and who has a left forearm graft, is assigned to the nurse and unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the nurse? 1. The UAP avoids using soap while bathing the client. 2. The UAP takes the BP on the client's left arm. 3. The UAP tells the client she should not eat chips. 4. The UAP measures a scant amount of urine in the BSC.

2. The UAP takes the BP on the client's left arm.

The nurse is caring for clients in a family practice clinic. Which client should the nurse assess first? 1. The male client with chronic pyelonephritis who has costrovertebral tenderness. 2. The female client who is having burning and pain on urination. 3. The female client with urethritis who reports dysuria, urgency, and frequent urination. 4. The male client who has hesitancy, terminal dribbling, and intermittency.

2. The female client who is having burning and pain on urination.

The charge nurse on the renal unit is notified of a bus accident with multiple injuries and clients are being brought to the emergency department (ED). The hospital is implementing the disaster policy. Which action should the nurse take first? 1. Determine which clients could be discharged home immediately. 2. Call any off-duty nurses to notify them to come in to work. 3. Assess the staffing to determine which staff could be sent to ED. 4. Request all visitors to leave the hospital as soon as possible.

3. Assess the staffing to determine which staff could be sent to ED.

The home health (HH) aide caring for the client who is postoperative kidney transplant asks the home health nurse, "Why is the physical therapist coming to visit the client?" Which statement is the home health nurse's best response? 1. "The physical therapist will evaluate the client's swallowing difficulty." 2. "The physical therapist will assist the client with fine motor coordination." 3. "The physical therapist will assist with caregiver concerns and making referrals." 4. "The physical therapist will work with the client on strengthening and endurance."

4. "The physical therapist will work with the client on strengthening and endurance."

The elderly female client tells the nurse, "I have vaginal dryness and it hurts when my husband and I make love." Which priority intervention should the nurse discuss with the client? 1. Tell the client to discuss hormone replacement therapy with her HCP. 2. Encourage the client to refrain from having sexual intercourse. 3. Recommend the client use a vaginal lubricant prior to intercourse. 4. Explain to the client that vaginal dryness is not uncommon in the elderly.

3. Recommend the client use a vaginal lubricant prior to intercourse.

The client comes to the clinic reporting pain and burning on urination. Which action should the nurse implement first? 1. Assess and document the client's vital signs. 2. Determine whether the client has seen any blood in the urine. 3. Request the client give a midstream urine specimen. 4. Ask the client whether she wipes front to back after a bowel movement.

3. Request the client give a midstream urine specimen.

The charge nurse in a large outpatient clinic notices the staff members are arguing and irritable with one other and the atmosphere has been very tense for the past week. Which action should the charge nurse take? 1. Wait for another week to see whether the situation resolves itself. 2. Write a memo telling all staff members to stop arguing. 3. Schedule a meeting with the staff to discuss the situation. 4. Tell the staff to stop arguing or they will be terminated.

3. Schedule a meeting with the staff to discuss the situation.

The nurse is caring for an 84-year-old male client diagnosed with benign prostatic hypertrophy. The client has undergone a transurethral resection of the prostate (TURP) and is complaining of bladder spasms. Which intervention should the nurse implement first? 1. Administer an antispasmodic medication for bladder spasms. 2. Calculate the client's urinary output. 3. Palpate the client's abdomen for bladder distention. 4. Assess the client's three-way urinary catheter for patency.

4. Assess the client's three-way urinary catheter for patency.

Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP) when caring for the client who is 2 days postoperative open surgery of the kidney? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's flank surgical dressing for drainage. 3. Take and record the client's vital signs and pulse oximeter reading. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day

3. Take and record the client's vital signs and pulse oximeter reading. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day