PPL HESI Practice Questions

On the second postoperative day, a client is pulseless, apneic, and unresponsive. In what order should the nurse implement these nursing actions? (Arrange from first on top to last on the bottom.) Delegate emergency responsibilities. Call for assistance. Initiate chest compressions. Ventilate the client.

1. Call for assistance. 2. Initiate chest compressions. 3. Ventilate the client. 4. Delegate emergency responsibilities. Rationale: Call for assistance, then based on the recommendations of the American Heart Association (AHA), high-quality chest compressions should be the first action in CPR. The sequence is compressions, airway, and breathing (CAB). Delegating emergency responsibilities is last.

According to the nurse practice act, a state board of nursing is not permitted to take which action? a. Expand the state-legislated nursing scope of practice. b. Reduce the state-legislated nursing scope of practice. c. Implement licensing sanctions against unsafe nurses. d. Approve the establishment of new nursing programs.

a Rationale: According to the nurse practice act, a state board of nursing cannot expand the state-legislated nursing scope of practice. The nurse practice act is defined and guided by each individual state and also establishes the state nursing board as well as the powers it possesses. A change to the nursing scope of practice must be approved by a vote in the state legislature.

The nurse is preparing to provide a report of a client to another colleague who will be assuming care of the client. Which information is most important to be included in the report? a. Brief medical history. b. Dietary preferences. c. Scheduled procedures. d. Psychosocial history.

a Rationale: A brief medical history should be included when providing a report so the receiving nurse can effectively assess and monitor the client. Dietary preferences, scheduled procedures, and psychosocial history should be communicated, but are not the most important pieces of information.

The nurse manager wants to promote team building among the staff on the unit. Which technique should the nurse manager consider using? a. Coaching. b. Listening. c. Appraisal. d. Empowerment.

a Rationale: The nurse manager should use coaching to foster team building. When implemented in a planned, organized, and caring manner, coaching can encourage team building that helps to improve staff work performance as well as professional confidence and engagement.

Which action should the nurse delegate to an unlicensed assistive personnel (UAP) that promotes client safety? a. Assign the UAP to help clients who require assistance with activities of daily living. b. Ask the UAP to obtain vital signs every 15 minutes for a client receiving a blood transfusion. c. Direct the UAP to assist a client with a hip fracture with ambulation and toileting. d. Instruct the UAP to administer prescribed medications to each client after breakfast.

a Rationale: Assigning unlicensed assistive personnel (UAP) to help clients who require assistance with activities of daily living (ADLs) is an example of a delegation that promotes client safety.

The nurse is caring for a client who has suddenly become unconscious. Which type of decision-making process should the nurse use in this situation? a. Autocratic. b. Creative. c. Paternalistic. d. Optimizing.

a Rationale: Autocratic decision-making involves one person making a decision, and it is necessary for crisis situations when rapid decision-making is required.

A client reports to the day shift nurse that every time the night shift nurse is on duty, the pain medication does not work. Which action should the nurse take? a. Consult with the nurse manager about the client's concerns. b. Discuss the client's statement with the night shift nurse. c. Review the dosage of medication that is being administered at night. d. Examine the client's documented pain scores prior to being medicated at night.

a Rationale: Because there is a concern voiced by the client of inadequate pain relief when care is provided by the same nurse each night, the nurse manager should be notified. The nurse manager will investigate and if the findings require a mandated report, the nurse manager is most familiar with the healthcare organization and legal protocols for doing so.

The nurse manager is reviewing clinical indicators to evaluate the effectiveness of staffing. Which measurement should the nurse include in the review? a. Client length of stay. b. Overtime. c. Sick time. d. Staff turnover rate.

a Rationale: Clinical or service indicators are client-focused indicators used to evaluate the effectiveness of staffing and quality of care. Length of stay is an example of a clinical indicator that can be useful in evaluating the effectiveness of staffing.

The charge nurse is implementing coaching techniques with the staff to improve client outcomes on the unit. Which technique should the charge nurse consider using for coaching to be effective? a. Provide frequent and regular interactions. b. Reduce interactions to large group settings. c. Institute brief and spontaneous interactions. d. Limit one-on-one interactions with individuals.

a Rationale: Coaching can be done on an individual basis or can involve a team approach and it consists of frequent and regular interactions with staff. Coaching enhances communication and provides for an active appraisal process between the charge nurse and the nursing staff.

The nurse is planning to discuss the advantages of Computer Provider Order Entry (CPOE) during a staff meeting. Which feature should the nurse include? a. Automatically calculates the dose. b. Decreases time spent on medication tasks. c. Allowance for increased variation in practice. d. Reduces the need for the six rights of medication administration.

a Rationale: Computer Provider Order Entry (CPOE) is one of many software applications that are used in healthcare settings. One of the advantages of CPOE is automatic dose calculation. The nurse is still responsible for performing the six rights of medication administration.

The nurse is caring for a client with rhabdomyolysis after sustaining multiple crushing injuries. Which intervention should the nurse include in the plan of care to prevent acute renal failure? a. Central venous catheter insertion for hydration. b. Blood specimen collection for electrolyte analysis. c. Antiinflammatory and opioid analgesics for pain. d. Diuretic IV administration for third-spacing fluids.

a Rationale: Crushing injuries release myoglobin (rhabdomyolysis) into the circulation, which can occlude distal renal tubules and cause acute tubular necrosis (ATN) or renal failure. To prevent renal complications, the nurse should prepare the client for the administration of copious IV fluids after CVC insertion to enhance urinary secretion of myoglobin and iron byproducts.

A nurse who is caring for a group of clients in the medical department has one unlicensed assistive personnel (UAP) assigned to the same group of clients. Which task should the nurse assign to the UAP? a. Accompany a discharged client with chronic kidney disease (CKD) to a private car. b. Pick up clients' lunch trays and take them to the dietary department. c. Obtain a STAT serum glucose level for a client who has a low glucometer reading. d. Change the bed linens for a client who is being transferred to the rehabilitation unit.

a Rationale: Hospitals require clients to be escorted by hospital personnel to the client's car. This nursing task could be delegated to the UAP.

A client is being transferred from one unit to another unit. Which action should the nurse perform first? a. Identify the client. b. Assess the client. c. Review the client's history. d. Reconcile the client's medications.

a Rationale: Identification should be verified first for all clients who are admitted to a new unit, as well as prior to being transferred from a unit. Identifying clients correctly is a part of the National Patient Safety Goals of the Joint Commission.

The nurse is seeking information regarding a nurse's authority when delegating tasks to unlicensed assistive personnel (UAP). Which resource should the nurse use to obtain the information? a. State Nurse Practice Act. b. American Nurses Association. c. National League for Nursing. d. National Council of State Boards of Nursing.

a Rationale: Information related to delegation authority resides in the nurse practice act for each state. The American Nurses Association and National Council of State Boards of Nursing have published a joint statement that provides general guidelines for delegation decisions for nursing practice.

Which statement describes why is it important for nurses to develop a pattern of lifelong learning throughout their careers? a. Knowledge of technology and practice changes are needed to keep clients safe. b. Annual continuing education is a requirement for nurses in practice. c. Nurses must prepare for future professional promotions and raises. d. State nursing boards identify lifelong learning as a directive for nurses.

a Rationale: Lifelong learning has become a necessity in all healthcare fields due to ongoing advancements in technology and developments in clinical research. Nurses need to be knowledgeable about the changes in technology and clinical practice in order to keep their clients safe.

Which statement best describes managed care that is implemented by a specific healthcare delivery agency? a. Each member of the healthcare team performs specific tasks for client care to ensure the implementation of a client's critical pathway. b. One nurse is responsible for the total nursing process required to meet the client's needs throughout hospitalization. c. The nurse collaborates with other healthcare disciplines to plan and implement coordinated client care. d. The healthcare provider provides direction for the nurse to assess, plan, and coordinate the client's care.

a Rationale: Managed care refers to a system in health care delivery that structures the use, cost, quality, and effectiveness of health services and includes pre-authorization, diagnostic-related groups (DRGs), critical paths, case management care plans, and variance analysis. Primary nursing is a nursing care model that ensures autonomy, authority, and accountability in providing the total nursing process for the client during a period of hospitalization. Case management is under the umbrella of managed care as a cost-containment strategy and a nursing care delivery model that coordinates standardized patterns of care and length of hospitalization. Managed care relies on the healthcare provider as the gatekeeper to minimize unnecessary utilization.

The nurse is creating a mentoring program for recently graduated nurses assigned to the unit. Which outcome should the nurse recognize as the primary benefit of mentoring for a new nurse? a. Self confidence. b. Listening skills. c. Developed expertise. d. Career commitment.

a Rationale: Mentoring helps a new nurse develop self-confidence. Mentors are experienced professionals who develop a relationship with less experienced nurses to provide support, be a source of information, and promote individualized professional development.

A hospital received a bomb threat. While the fire department personnel are evacuating the clients, which action should the charge nurse perform? a. Obtain a current roster of clients assigned to the unit. b. Ensure that the narcotics are secured and locked up. c. Move clients' medical records to a safe location. d, Notify the operator when the unit is evacuated.

a Rationale: Obtaining a current roster of clients assigned to the unit will help the fire department ensure that all clients are evacuated. In this possibly life-threatening situation, evacuation of personnel and clients is a high-priority action. The hospital operator should also be evacuated.

The nurse is assigning client care tasks to an unlicensed assistive personnel (UAP). Which task should the nurse include in the assignment? a. Provide basic hygiene for a client with a stroke. b. Begin initial ambulation of a postoperative client. c. Assist a client to physical therapy. d. Feed a client who has dysphagia.

a Rationale: Staff members differ in their knowledge, skills, and competencies for safe client care. The nurse can delegate activities of daily living (ADLs), comfort care, and basic hygiene tasks to a UAP.

The nurse manager is reviewing time management skills and the use of technology during work hours with the nursing staff. Which statement made by a nurse indicates further teaching is required? a. I will limit my time spent on social media. b. I will create a folder for my priority email. c. I will avoid answering emails from friends. d. I will learn to use technology more efficiently.

a Rationale: Technology can be used as a beneficial tool or it can be an inefficient use of time. Social networking sites should be avoided, not just limited, during work hours.

The charge nurse is assessing clients who are currently in labor. It is most important for the pediatric healthcare provider to be present for which delivery? a. 40-week primigravida with hypertension who is receiving magnesium sulfate 2 grams/hour. b. 37-week multipara who is receiving penicillin G 2.5 million units IV for Group B Streptococcus. c. 41-week multipara who is requesting an epidural instead of a local anesthetic for delivery. d. 39-week primigravida with a positive urine drug screen who is receiving antiretroviral therapy.

a Rationale: The charge nurse should request that a pediatric healthcare provider attend the delivery of the client who is receiving magnesium sulfate for hypertension because magnesium sulfate crosses the placental barrier and causes CNS depression in the infant.

At which point of care should the nurse be aware of in reference to when most medication errors occur with older clients? a. Care transitions. b. Medication administration. c. Home health visits. d. Community healthcare clinics.

a Rationale: The highest risk of medication errors for older clients occurs during care transitions across settings. Incidents that involve moving a client into an extended care facility from the home or a facility, pose a greater risk to a client's harm than compared to other errors in care. Complex medication regimens and the inability to direct their own care due to medical and cognitive impairment, place extended-care residents at higher risk for medication errors. Errors occurring in transition were most likely to be caused by transcription errors, communication problems, unavailability of medications, medication name confusion, and pharmacy dispensing.

To implement change in the work environment, which action is most important for the nurse-manager to take? a. Solicit input from coworkers at the beginning of the process. b. Present to coworkers the advantages of using a different plan. c. Examine similar change processes in other institutions. d. Evaluate the feasibility of implementing the proposed change.

a Rationale: The most important component for successful change is soliciting input from coworkers which gives all team members ownership in the change. Although a successful change process involves cognitive exposure to the change idea and working to generate alternative solutions, soliciting input best ensures cooperation and the success of the change.

Which is the most important reason for the new nurse to review organizational policies during employee orientation? a. Policies indicate the organization's intentions for achieving goals. b. Policies are the list of rules everyone has to live by while at work. c. Policies provide the traditions for socialization in the organization. d. Policies tell nursing leaders how to solve problems as they arise.

a Rationale: The most important reason to review organizational policies during new employee orientation is to learn the organization's intentions for achieving its stated goals. Policies provide guidelines for organizational decision-making; however, they are not a list of rules, nor do they tell nurse leaders how to solve problems. Policies may include some organizational traditions, but these practices are not a primary focus of organizational policies.

According to Gardner's Leadership model, which nursing role is most involved in representing the nursing unit service and the organization to staff, other departments, professional disciplines, and the community? a. Nurse manager. b. Unit staff nurse. c. Nurse executive. d. Nurse researcher.

a Rationale: The nurse manager's role is most involved in representing the nursing unit service and the organization to staff, other departments, professional disciplines, and the community, according to Gardner's Leadership model. Unit staff nurses represent the nursing profession and the organization to clients and their families, and nurse executives represent the organization more generally to internal and external constituents.

Before taking measures to solve a problem on the unit, which should the nurse consider first? a. The importance of the problem. b. The authority required to solve the problem. c. The qualifications needed to solve the problem. d. The availability of resources to solve the problem.

a Rationale: The nurse must determine if the problem is important enough to try to solve before using and allocating time, energy, and resources.

A client reports feeling overwhelmed and lacking the ability to manage the prescribed treatment while at home. Which personnel should the nurse contact? a. Case manager. b. Nursing supervisor. c. Healthcare provider. d. Social worker

a Rationale: The nurse should contact the case manager for clients who report feeling overwhelmed about prescribed treatments to be done at home. The case manager is the healthcare team member who coordinates client care in the hospital and the services for continuity of healthcare after hospital discharge to best manage optimal, cost-effective, health outcomes.

The primary nurse receives the 0700 shift report for 4 clients on a medical unit. When prioritizing care, which action should the nurse implement first? a. Administer insulin per sliding scale to a client with a capillary glucose of 285 mg/dL. b. Assess the lung sounds of a client with pneumonia who is ready to go home. c. Flush the lumen of a client's triple lumen central venous catheter with saline. d. Review the potassium levels of a client who receives a daily loop diuretic.

a Rationale: The nurse should first administer the insulin per scaling scale to the client with hyperglycemia to prevent further elevation of the serum glucose levels.

The nurse is reviewing the charts of clients who may require social service referrals. The nurse should obtain a request for a social services consult for which client? a. A client admitted for injuries from a domestic violence dispute. b. An intoxicated client who was involved in a motor vehicle collision. c. A child with an infected surgical incision who was readmitted. d. An older adult client admitted from home with a urinary tract infection.

a Rationale: The nurse should obtain a consultation request for social services for the client who has experienced injuries from a domestic violence dispute. Social workers can help clients in need identify support services and resources in the community to help with their circumstances.

The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? a. Violation of ethical principles. b. Poor time management skills. c. Dissatisfaction of co-workers. d. Reduction of client complaints.

a Rationale: The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for care. This reflects a violation of the ethical principle of justice.

The nurse is reviewing the chart of a client with dysphagia for feeding recommendations. Which healthcare team member's documentation should the nurse review? a. Speech pathologist. b. Rehabilitation nurse. c. Registered dietitian. d. Physical therapist.

a Rationale: The speech pathologist screens and tests clients for dysphagia. Based on assessment findings, the recommendation for appropriate foods and feeding techniques should be documented by the speech pathologist.

According to Roger's Innovation-Decision Process theory, which staff member should the nurse manager seek to lead an important technology change on the unit? a. The nurse most often sought out on the unit for advice. b. The nurse who thrives on making many unit changes. c. The nurse who prefers not to change but will accept it. d. The nurse who enjoys keeping unit traditions the same.

a Rationale: The staff member best suited to lead an important technological change is the nurse who is most often sought out for advice. According to Roger's Innovation-Decision Process theory, this nurse is one whom others considered credible and should be one the first staff members to be trained and made as one of the early adopters. This staff member should be considered essential to help make this change accepted by others and to help others implement the change.

When prioritizing nonclinical tasks, which criteria should the nurse manager use? a. Select the most important and urgent task. b. Identify which task will take the longest. c. Determine the easiest task to complete. d. Establish if any tasks are clinically urgent.

a Rationale: When prioritizing nonclinical tasks, the best criteria to use is to find the task that is both important and urgent. Tasks can be important but not urgent, and they can be urgent but not important. Selecting the task that is both important and urgent is the best way to decide where to begin.

Which resources should the nurse utilize when faced with an ethical dilemma? (Select all that apply.) a. Institutional policy. b. Personal judgment. c. Trusted colleagues. d. Legal precedent. e. Personal feelings.

a, b, c, d Rationale: Resources that are available to help nurses with ethical decision-making include institutional policy, ethics committees, personal judgment, trusted co-workers, and legal precedent. Personal feelings may provide insight related to a nurse's personal judgment; however, these may be unhelpful if feelings are solely considered and are in conflict with other ethical decision-making resources.

In which situations should a nurse manager use a competitive approach to resolving conflicts in the clinical setting? (Select all that apply.) a. When rapid and decisive action is necessary. b. When maintaining relational harmony is important. c. When seeking solutions to meet everyone's needs. d. When important but unpopular actions must be taken. e. When a collaborative approach to the conflict fails.

a, b, d Rationale: A nurse manager should use a competitive approach in resolving conflict in the clinical setting when a rapid, decisive action is necessary, and when important but unpopular actions must be taken. When a collaborative (attempting to meet all needs) approach to conflict fails, facilitating a compromise (give and take) would be the next approach to reach a resolution. Nurse managers are collaborating when seeking solutions to meet everyone's needs. When having harmonious relationships is important, accommodation (neglecting one's own needs to satisfy others) is the best approach to conflict management.

After initiating a prescribed blood transfusion for a client with anemia, the nurse delegates the initial 15-minute intervals of vital sign measurements to an unlicensed assistive personnel (UAP) before going to lunch. Which rights of delegation have been violated? (Select all that apply.) a. Right person. b. Right instructions. c. Right task. d. Right circumstance. e. Right supervision.

a, c Rationale: The nurse needs to delegate the task of vital sign measurement during a blood transfusion to the right person when leaving the floor for lunch. A practical nurse's or registered nurse's expertise or scope of practice is necessary to be able to evaluate vital sign measurements during a transfusion. While a UAP can perform the measurement, the analysis of the results is beyond the UAP's scope of practice.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Update the nutrition needs in the plan of care. b. Bathe an unconscious client with pressure injuries. c. Teach insulin self-administration to a client with Type 1 diabetes. d. Evaluate goal attainment for a client with a below-the-knee prosthesis.

b Rationale: Delegation requires determining which staff member is capable of performing what tasks. Basic hygiene is within the role of the UAP. Coordination and planning of care, teaching, and evaluating desired goal attainment or client outcomes are responsibilities outside the scope of practice for the UAP, and within that of the nurse.

A client is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the client is taken into a treatment room and asks to stay with the client. Which action should the nurse implement? a. Insist that the spouse wait outside the room while resuscitation is being performed. b. Allow the spouse to be present and ensure that a member of the team explains the care given and answers questions. c. Explain to the spouse that there will be no time for explanations during the resuscitation efforts. d. Advise the spouse that if unsuccessful, the resuscitation scene should not be the last memory of a loved one.

b Rationale: Research supports the positive benefits of family presence during invasive procedures and cardiopulmonary resuscitation to clients, families, and staff. Facilitating family presence allows the family to view themselves as active participants and completes the last step of the secondary survey in the care of an emergency client. Someone should be assigned to the family to explain the care being delivered and to answer questions.

The director of nursing of a long-term care facility is developing a quality improvement project for the facility's units and established that a goal of the project should be consistent documentation of pain for all residents. Which statement is the best indicator of this goal's achievement? a. All of the nursing staff attend mandatory in-service sessions. b. After one month, an audit shows a 20% improvement in documentation. c. Random selection of a nurse's charts shows thorough documentation. d. The staff agrees that documentation has improved by 80%.

b Rationale: The best indicator that learning has taken place is evidence of change in behavior, which is indicated by a 20% improvement as evidenced by an electronic medical record (EMR) audit after one month. Attending mandatory in-service does not necessarily mean learning takes place or that there is an ability to apply the new information. While one nurse is achieving the desired goal, it does not indicate the project is achieving overall staff improvement in computer documentation. Opinions lack objectivity and are not a qualitative evaluations.

A nurse receives an emphatic complaint from a client in a semi-private room that the night shift nurse did not come into the room the entire night. Which action should the nurse implement first? a. Telephone the night shift nurse as soon as possible to ask about the situation. b. Review the night shift nurse's documentation with the charge nurse. c. Discuss the situation with staff to determine if this client has a history of complaining. d. Verify occurrence with client's roommate while he's ambulating in the hall.

b Rationale: The client's concern needs to be assessed immediately. This can best be accomplished by reviewing the documentation with administration, i.e., the charge nurse, to determine the client's needs and the night nurse's response. The night shift nurse may need to be contacted at some point, but reviewing the documentation should occur first.

Female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother's original request, which was executed when she was healthy. What information is best for the nurse to provide? a. Client's original request based on the signed living will for no heroic measures should be followed. b. Family should be guided to support the client's current decision. c. Client's cognitive ability should be evaluated before the use of a ventilator is needed. d. Family should discuss alternative treatment options with the HCP.

b Rationale: The client's verbalization to accept the ventilator or other treatment should be honored because it is sufficient validation to revoke the client's living will. If the client is cognizant and can make their own decisions, then the living will stands. If the client becomes unable to make their own decisions, then the family knows what course the client wishes to take.

The nurse-manager wants to assign an agency nurse to a client who has a new tracheostomy. Which action should the nurse-manager implement? a. Assign the nurse to the client with the tracheostomy and evaluate the care given. b. Ask the nurse about her competency to care for the client with the tracheostomy. c. Request the agency to send a nurse who is experienced with tracheostomy care. d. Transfer the client to another nurse and use the agency nurse for basic hygiene tasks.

b Rationale: The nurse-manager should verify the competency of the agency nurse by soliciting information about the specific skill before the beginning of a shift or assignment.

A Spanish-speaking client is scheduled for surgery in the morning and preoperative teaching needs to be completed. Since the primary care nurse speaks very little Spanish, which person is best to translate the instructions to the client? a. A Spanish-speaking UAP who has worked on the unit for many years. b. The client's husband who is an attorney at a large local law firm. c. A practical nurse working on another unit who speaks fluent Spanish. d. The primary care nurse with the help of the Spanish-speaking UAP.

c Rationale: A Spanish-speaking nurse has the most knowledge about preoperative teaching and has the best command of the language, so this is the best person to provide translation services. Despite long-term employment on the unit, the UAP does not have the same knowledge base as a practical nurse. The husband is personally involved and does not have knowledge about preoperative care. Spanish-speaking expertise is necessary to accurately implement preoperative teaching, and the UAP's assistance does not provide adequate language expertise.

A nurse sitting in the hospital cafeteria sees a man place a small box in the corner and then look around as though he is trying to determine if anyone is looking at him. He then walks quickly to the cafeteria exit. Which action should the nurse implement first? a. Make a mental note of the appearance of the man. b. Alert the kitchen staff and have them call 911. c. Use the nearest phone to notify hospital security. d. Calmly instruct everyone in the cafeteria to leave.

c Rationale: All hospital staff should be alert for suspicious behavior. When such a situation is reported, the hospital security handles it by implementing actions that are based on the policies and procedures the security department is trained to follow in this type of situation.

A new graduate nurse places a folder on the food cart so intake can easily be recorded, but at the hospital where the nurse is employed, intakes are often estimated because no recordings are made as the trays are picked up. At a staff meeting, the nurse suggests that the recordings be made as trays are picked up. Which factor related to entry into practice is the nurse-manager using when the suggestion moves to the implementation of a policy? a. Nurturing. b. Mentoring. c. Biculturalism. d. Role modeling.

c Rationale: Biculturalism is the merging of learned ideals with the values of the workplace. Role modeling involves observing experienced nurses, often in leadership positions, to internalize desired qualities during role transition. Nurturing means encouraging and supporting nurses as they learn and grow. Mentoring is a mutual interactive method of learning in which a knowledgeable nurse inspires and encourages a novice nurse.

The practical nurse (PN) is working with the registered nurse (RN) to provide care for several clients. Which task should the RN, rather than the PN, perform? a. Apply a neck brace prior to ambulating a client on the first day after a cervical laminectomy. b. Assist a healthcare provider in performing a joint fluid aspiration of a client's knee. c. Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. d. Remove the staples from a client's incision one week after hip arthroplasty.

c Rationale: Care of a stage IV pressure ulcer is a complex, sterile procedure that requires assessment of the wound, and evaluation of the effectiveness of the treatment plan, and should be performed by the RN.

What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? a. Designate 15 minutes a day to respond to each time-waster. b. Delegate other nursing responsibilities to the team members. c. Schedule specific times on a written calendar to review 2 charts per day. d. Review all records 2 days before the due date to focus on the deadline.

c Rationale: Creating a disciplined approach by scheduling time periods for each issue is the most effective time-management strategy.

Based on the scope of practice of the practical nurse (PN), which task should the nurse assign to the PN? a. Transport a client to x-ray. b. Restock sterile supplies. c. Assist with a lumbar puncture. d. Distribute afternoon nutrition supplements.

c Rationale: Delegation should include the right task, the right skill, and knowledge about the responsibilities of the PN or UAP. The PN's scope of practice includes assisting with a lumbar puncture.

Which task should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? a. Evaluate the ability of a client to swallow ice one hour after a gastroscopy. b. Assist a client with initial ambulation after a hip replacement using a walker. c. Obtain a sterile urine specimen from an indwelling catheter with a closed drainage system. d. Change the disposable tracheostomy inner cannula when secretions become tenacious.

c Rationale: Functions of assessment, evaluation, and nursing judgment are performed by the registered nurse (RN). The collection of sterile urine specimens falls within the role of the UAP.

A single-parent mother brings her 3-year-old daughter to the emergency department after the child fell off a playground swing at school and hit her head. Which finding should prompt the nurse to advocate for continued hospital observation of the child instead of discharging the child to care at home? a. The mother states they do not have the money to pay for transportation home. b. The child had a 10-second loss of consciousness immediately after the fall. c. The mother is slurring her words and is not attentive to discharge instructions. d. The child indicates that she is tired and wants to take a nap.

c Rationale: Having a responsible adult to make ongoing observations is the most important criterion for discharging anyone to their home after a head injury. The child, who needs observation, should not go home with an impaired adult. Alternative arrangements can be made regarding follow-up care. The events of the head injury do not necessarily indicate the need for hospitalized observation. It is normal to be drowsy after a concussion; immediate intervention is needed if the child cannot be aroused from sleep.

The nurse is planning a diabetes education course for a group of clients newly diagnosed with diabetes mellitus. Which collaborative approach is the best use of interdisciplinary team members? a. Schedule the pharmacist to teach about the treatment of hypoglycemia. b. Assign the occupational therapist to teach insulin injection techniques. c. Invite the dietician to discuss the timing of meals and snacks. d. Ask the physical therapist to discuss scheduling physical activity.

c Rationale: The dietician can provide the best expertise regarding diet and mealtime planning for clients with diabetes mellitus. The pharmacist's expertise focuses on medications, not the client's management of hypoglycemia, which includes both food intake and medication actions. The occupational therapist (OT) is skilled in implementing interventions to help the client improve small manipulative skills, but the OT does not have the expertise related to medication administration, which is a nursing responsibility. The physical therapist's expertise involves a treatment plan in therapeutic exercises, but may not focus on the scheduling of activity with diet and medication actions, such as peak, and duration.

A nurse is concerned about the way medications are being administered in the nursing unit. Which action should this nurse implement? a. Discuss concerns with other nurses on the unit. b. Continue with the present unit policy and procedures. c. Propose an alternative method to administer the medications. d. Relay the perceived problem to the director of nursing services.

c Rationale: To facilitate change, an alternative method should be suggested to managerial nursing staff.

The home health nurse is planning care for a client with diabetes. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Notify the healthcare provider of a blood glucose > 400 mg/dL. b. Explain the procedure for inspecting the feet daily. c. Clean the kitchen and bathroom before leaving. d. Assist with bathing and other activities of daily living.

d Rationale: Assisting the client with activities of daily living is within the scope of practice for a UAP. UAPs may not take verbal prescriptions from healthcare providers, so the nurse, not the UAP, should inform the healthcare provider about the elevated blood glucose level in case treatment is prescribed. Housekeeping duties are not tasks that the nurse needs to delegate to a UAP employed by home healthcare agencies.

The labor and delivery nurse calls the healthcare provider to report the onset of late decelerations of the fetal heart rate in a laboring client. The healthcare provider tells the nurse to continue monitoring the client and to call back in one hour. Which initial action should the nurse take? a. Continue to monitor the client per the provider's instructions. b. Report the provider's response to the chief of the medical staff. c. Ask the client's husband to call the healthcare provider. d. Call the nursing supervisor to report the current situation.

d Rationale: Because the onset of late decelerations requires immediate intervention and the presence of the healthcare provider, the nurse should follow the chain of command and immediately notify the nursing supervisor.

A nurse who is working the 2300 to 0700 shift enters a client's room when the pulse oximeter alarms and reads 82%. The client appears to be sleeping. Which action should the nurse take first? a. Gently apply oxygen without waking the client. b. Record the reading and monitor for further decrease. c. Reposition the pulse oximeter until it stops alarming. d. Rouse the client and obtain vital signs.

d Rationale: It is most important for the nurse to assess the client's respiratory status, even if the client must be awakened to do so.

Four clients arrive at the mental health unit for admission at the same time. Which client should the nurse assess first? a. An older adult with Alzheimer's disease who is confused. b. A young adult with phobias that interfere with daily activities. c. An adult with schizophrenia who stopped taking medications. d. A middle-aged adult with acute mania who is pacing the hallway.

d Rationale: The nurse should first assess the client with symptoms of mania and hyperactivity because if the client's judgment is extremely poor, there is a potential for risk of injury to self and others, and the client may need constant observation. The other clients can be monitored by another staff member until the nurse can complete the assignments.