1137 Exam 2

A young woman will receive 6 months of chemotherapy for cervical cancer. She is a single parent of two young children and can no longer work. The nurse contacts a social worker to help plan continuing care. The client states, "I feel overwhelmed. How can the social worker help me?" Which responses by the nurse about the role of the social worker are appropriate? Select all that apply. -"The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." -"The social worker can assist in locating resources and programs to assist you during your treatment." -"Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." -"Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources."

-"The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." -"The social worker can assist in locating resources and programs to assist you during your treatment." -"Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." -"Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources."

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? -administer the prescribed preanesthetic medication -note this new allergy prominently on the medical record -contact the scrub nurse in the operating room -inform the anesthesiologist.

-Inform the anesthesiologist.

A client with peptic ulcer disease is admitted to the hospital for a gastric resection. The client reports a sudden sharp pain in the midepigastric area that radiates to the shoulder. What should the nurse do first? -establish an IV line -administer pain medication -notify the surgeon -call for a stat ECG

-Notify the surgeon.

Two unlicensed assistive personnel (UAP) are discussing which person is responsible for taking the dirty linen bags into the utility room. One UAP approaches the charge nurse and complains about the other. Which action should the nurse employ? -advise the UAP to be more tolerant of his coworker -tell the UAP to take care of the linen bags himself -urge the UAP to discuss the problem with his coworker. -take care of the linen bags to avoid further conflict

-Urge the UAP to discuss the problem with his coworker.

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed? -immediately go to the client's room and assess VS, administer O2 at 2 L/min, and notify the provider -ask the assistive personnel to notify the provider of the low pulse oximeter level -ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. -complete the assessment of the new client before attending to the client who underwent laminecto

-Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? -inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center -review and revise the way client education is conducted in the surgeons' office -because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaint -Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

-Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation? -notify the nurse manager that the assignment will be refused -bring reference materials to the room when providing care -pretend to be ill and leave the unit as soon as possible -suggest a shared assignment with a senior staff nurse

-Suggest a shared assignment with a senior staff nurse.

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? -tell the charge nurse that the nurse is going to lunch -verify that the charge nurse has assigned someone else to take care of the client -Give the charge nurse information about what care should be given while the nurse is at lunch. -remind the charge nurse about the client's history and current medication

-Give the charge nurse information about what care should be given while the nurse is at lunch.

The intensive care nurse responds to a cardiac arrest on a medical-surgical unit. The code leader delegates to the intensive care nurse the task of documenting the medical emergency. What actions will be done by the intensive care nurse? Select all that apply. -Identify the client with two identifiers. -Record the treatments and assessments done by the code team. -Review the client's medication record. -Include vital signs at frequent intervals. -Identify vital sign changes with medication administration.

-Identify the client with two identifiers. -Record the treatments and assessments done by the code team. -Include vital signs at frequent intervals.

The nurse is assigned the care of a client with acute renal failure and hypernatremia. Which actions can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. -Monitor for dehydration. -Obtain and monitor vital signs. -Administer IV fluid. -Oral care every 4 hours. -Urinary catheter insertion.

-Obtain and monitor vital signs. -Oral care every 4 hours

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? -Make sure the UAP has practiced sterile technique on at least one other occasion. -Reassign the UAP to a client requiring basic tasks that the UAP has mastered. -Supervise the UAP during the treatments involving sterile technique. -Provide the UAP with a list of resources to guide the implementation of care.

-Reassign the UAP to a client requiring basic tasks that the UAP has mastered.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? -Registered nurse with one year of experience -licensed practical nurse with 5 years of experience -nursing assistant with 15 years of experience -charge nurse with 10 years of experience

-Registered nurse with one year of experience

A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation? -notify the nurse manager that the assignment will be refused -bring reference materials to the room when providing care -pretend to be ill and leave the unit as soon as possible -suggest a shared assignment with a senior staff nurse.

-Suggest a shared assignment with a senior staff nurse.

A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse's understanding of the case manager? -The case manager collaborates care among all health care partners with the client in the center. -the case manager is responsible for all healthcare choices and all decisions should start with the case manager -the case manager for the whole client including the dietary and psychosocial needs -the case manager is aware of all needs of the client during the hospitalization and provides for them after the client returns home

-The case manager collaborates care among all health care partners with the client in the center.

After the family leaves, a Muslim client admitted for gastroenteritis explains that prayers must be performed five times a day even while in the hospital. The client later asks which direction is west. What should the nurse recognize in this client? Select all that apply. -The client loves nature and watching sunsets each evening. -The client plans to wave goodbye as the family drives away. -The client is demonstrating an active faith practice. -The client is advocating to be able to meet religious needs. -The client is successfully communicating spiritual needs.

-The client is demonstrating an active faith practice. -The client is advocating to be able to meet religious needs. -The client is successfully communicating spiritual needs.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? -Determine that the procedures currently in place must be followed and direct staff to follow them without question -tell staff members to use whatever procedures they feel are best -ask staff members to quickly meet among themselves and decide what procedures to follow -tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do

-Determine that the procedures currently in place must be followed and direct staff to follow them without question

A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? -medicate the client and document his comment -withhold the medication and notify the physician immediately -explain the cardiac catheterization does not involve open heart surgery, and then medicate the client -withhold the medication and notify the physician immediately

-Withhold the medication and notify the physician immediately

A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do? -remind the LPN that it is the LPN's duty to administer the medications. -do nothing because the client has been taking the medication for a long time -allow the nursing assistant to administer this dose and tell the LPN later that it's the LPN's duty to administer the medication -take the medication from the nursing assistant and administer it

-Remind the LPN that it is the LPN's duty to administer the medications.

A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? -when the float nurse gives a written report to the oncoming nurse -when the nurse receives a critical lab value via phone or in-person from the lab -when the lab report shows up on the computerized medical record -when the unit clerk takes a telephone prescription for a stat lab test

-When the nurse receives a critical lab value via phone or in-person from the lab

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? -Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. -Review and revise the way client education is conducted in the surgeons' office. -Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. -Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

-Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? -inform the nurses who work in the facility that client education should be implemented as soon as the client admitted to either the hospital or the outpatient surgical center -review and revise the way client education is conducted in the surgeons' office -because none of the clients suffered any serios damage, the nurse manager can safely ignore their complaints -Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

-Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report? -current client assessment -client's admission number -nursing treatment initiated -results of laboratory test

current client assessment

The nurse is caring for a client with acute renal failure and edema. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply. -Administer furosemide orally twice a day. -Make sure the urinal is within the client's reach. -Assess breath sounds. -Remind the client that all urine is to be saved for intake and output measurement. -Weigh the client every morning using the standing scale. -Measure and record vital signs.

-Make sure the urinal is within the client's reach. -Remind the client that all urine is to be saved for intake and output measurement. -Weigh the client every morning using the standing scale. -Measure and record vital signs.

A client receiving chemotherapy for cancer has an elevated serum creatinine level. What should the nurse do next? -cancel the next scheduled chemotherapy -administer the scheduled dose of chemotherapy -notify the health care provider (HCP) -obtain a urine specimen

-Notify the health care provider (HCP).

The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions? -"I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container" -"I'll disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container" -I'll empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag" -"I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."

-"I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."

The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor? -"I will have to report to the supervisor if you can't do it" -"all clients have a right to compassionate and timely care" -"I will take care of any client needs that you can't provide" -"let's discuss how we can meet our clients' needs."

-"Let's discuss how we can meet our clients' needs."

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice? -a referral -a consultation -conferring -reporting

-A referral

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit? -administer morphine 4 mg IV bolus -teach a client with newly diagnosed diabetes how to perform blood glucose testing -administer zolpidem 5 mg as needed for sleep -transfuse 1 unit packed red blood cells

-Administer zolpidem 5 mg as needed for sleep

A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first? -OT -PT -psychologist -HCP

-HCP

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? -complete an initial assessment on a client -increase the oxytocin rate on a laboring client -perform a straight catheterization for protein analysis -assess a laboring client for a change in labor pattern

-Perform a straight catheterization for protein analysis.

A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? -instruct the client in methods for low-cost, highly nutritious meal preparation -determine whether the client qualifies for local assistance programs -refer the client to a social worker for enrollment in food assistance programs -ask the client if she has a job and the amount of income earned

-Refer the client to a social worker for enrollment in a food assistance program

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed? -Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the provider. -Ask the assistive personnel to notify the provider of the low pulse oximetry level. -Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. -Complete the assessment of the new client before attending to the client who unde

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take? -suspend the nurse who is acting out for the inappropriate behavior -call a break in the meeting and talk to the nurse in a private place. -ask the rest of the staff if they also feel the same way -tell the nurse who is acting out to settle down and to act professionally

Call a break in the meeting and talk to the nurse in a private place.

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? -suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying -weighing the unclothed infant at the same time every day -reporting the caregiver to social services for suspected abuse -requiring the caregiver to attend a community support group prior to discharge

Weighing the unclothed infant at the same time every day

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: -exhibit no further episodes of short-term memory loss -be able to return to his construction job in 3 weeks -actively participate in the rehabilitation process as appropriate -be emotionally stable and display pre-injury personality traits

actively participate in the rehabilitation process as appropriate.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? -prescribing adult diapers for the client so she will not have to worry about incontinence -requesting an indwelling urinary catheter to -avoid incontinence -padding the bed with extra absorbent linens -placing a commode at the bedside and instructing the client in its use

placing a commode at the bedside and instructing the client in its use

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? -providing passive ROM exercises to the left extremity during the bed bath -elevating the foot of the bed to reduce edema -pulling up the client under the left shoulder when getting the client out of bed to a chair -putting high top tennis shoes on the client after bathing

pulling up the client under the left shoulder when getting the client out of bed to a chair

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to -the physician on call -the social worker on call -Women in Distress -a lawyer

the social worker on call

Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task? -scheduling staff assignments for the next month -terminating a nursing assistant for insubordination -deciding on salary increases for nurses after the complete orientation -telling a staff nurse to initiate disciplinary action against one of their peers

-Scheduling staff assignments for the next month

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN? -a 41-year-old client with unstable angina -a 72-year-old client with diverticulitis -a 32-year-old client hospitalized for chemotherapy treatment -a 5-year-old client with Kawasaki's disease

-a 72-year-old client with diverticulitis

A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? -respiratory acidosis -respiratory alkalosis -metabolic acidosis -respiratory stress

respiratory acidosis

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks? -the RN must directly supervise all delegated tasks -after a task is delegated, it's no longer the RN's responsibility -The RN delegates a task based on the UAP's skill set. -follow-up with a delegated task is only necessary if the UAP is untrustworthy

-The RN delegates a task based on the UAP's skill set.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks? -the RN must directly supervise all delegated tasks -after a task is delegated, it's no longer the RN's responsibility -the RN delegates a task based on the UAP's skill set. -follow-up with a delegated task is only necessary if the UAP is untrustworthy

-The RN delegates a task based on the UAP's skill set.

A client with septic arthritis of the knee is admitted to the orthopedic floor. The nurse should consult the case manager if which complication occurs during hospitalization? -wound drainage -temperature elevation -decreased mobility -allergic reaction to antibiotics

-decreased mobility

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The health care provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply. -vital signs -enemas until clear -CBC -morphine -regular diet

-enemas until clear -regular diet

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? -rescheduling surgeries -ensuring that clients receive medications but -omitting full bathing when possible -allowing all medications to be given 2 hours late -asking unlicensed assistive personnel (UAPs) to assist in administering analgesics

-ensuring that clients receive medications but omitting full bathing when possible

Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which statement indicates the primary reason the nurse manager would perform an investigation to determine the causes of the falls? -"I would like to establish the causes and trends related to client falls." -"I want to determine exactly what happened and why the two clients fell." -"I would like to know which staff members were on duty when the falls occurred." -"I want to identify the environmental factors that contributed to the falls."

-"I would like to establish the causes and trends related to client falls."

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards? -"You should take the unit of blood. It will help you feel better." -"Do you have all the information you need for informed consent?" -"Do you have any questions that I can clarify for you?" -"Tell me how the nurse educator explained the procedure."

-"You should take the unit of blood. It will help you feel better."

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? -Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. -Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. -Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. -Ask the assistant manager to develop a plan for the review and revision of client-education materials.

-Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members.

A nurse manager notices that a number of medication errors have occurred on the unit with nurses giving hydralazine instead of hydroxyzine. What would be the most appropriate action for the nurse manager? -Consult with pharmacy to ensure distinct labeling of the medications. -Post the names of nurses making medication errors on a bulletin board. -Provide an in-service on the differences between hydralazine and hydroxyzine. -Require nurses to retrieve individual doses of the medications from the pharmacy.

-Consult with pharmacy to ensure distinct labeling of the medications.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? -Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. -Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. -Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. -Ask the staff nurses to form a task force to review and revise discharge policies and procedures.

-Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility.

A nurse-manager appropriately behaves as an autocrat in which situation? -planning vacation time for staff -directing staff activities if a client experiences a cardiac arrest -evaluating a new medication-administration process -identifying the strengths and weaknesses of a client-education video

-directing staff activities if a client experiences a cardiac arrest

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? -Find another nurse to cover the unit and send the nurse back to the surgery unit. -Tell the nurse to buddy up with someone else and do the best that the nurse can do. -Tell the nurse that as an RN, the nurse should be competent to work in any area. -Give the nurse the lightest workload on the unit.

-Find another nurse to cover the unit and send the nurse back to the surgery unit.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. What should the nurse do? -Reinforce the UAP's use of this intervention over the bony prominence. -Explain to the UAP that massage is effective because it improves blood flow to the area. -Inform the UAP that massage is even more effective when combined with the use of lotion. -Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

-Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. -Obtain vital signs. -Initiate oxygen therapy as needed. -Apply antiembolic stockings. -Assess the client's breath sounds. -Keep the client oriented.

-Obtain vital signs. -Apply antiembolic stockings. -Keep the client oriented.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? -Registered nurse with one year of experience -Licensed practical nurse (LPN) with five years of experience -Nursing assistant with 15 years of experience -Charge nurse with 10 years of experience

-Registered nurse with one year of experience

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP? -All nursing activities performed by the UAP should be directly supervised by a registered nurse. -Some nursing activities performed by the UAP should be directly supervised by a registered nurse. -The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. -The UAP has previously completed and practiced the delegated activities.

-The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? -The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. -Because the nurse-manager is off duty and not accountable for incidents that occur in their absence, the nurse-manager need not be notified. -The nurse-manager only needs to be informed of the incident when the nurse-manager reports to work on the next scheduled day. -Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits.

-The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

A nurse manager is reviewing charts of several toddlers on a pediatric unit. The manager notices that the weight of the toddlers has not been documented and decides to address the issue with the staff. Which is the most critical information for the nurse manager to share with the staff regarding this situation? -Undocumented weights could result in medication errors. -Weights are necessary to plan pediatric meals accurately. -Failing to chart weights will lead to a work suspension. -Documenting weights helps parents see a child's progress.

-Undocumented weights could result in medication errors.

A registered nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which client's care will the nurse safely delegate to the UAP? -a client with a suprapubic catheter that is draining burgundy-colored urine -a client returning from the post-anesthesia unit after radical suprapubic prostatectomy -a client diagnosed with renal calculi who is encouraged to ambulate four times daily -a client with mild hematuria who requires bladder irrigation via urinary catheter

-a client diagnosed with renal calculi who is encouraged to ambulate four times daily

A nurse is working as part of team on the unit on a performance improvement initiative to address a concern that clients are not receiving adequate preoperative teaching. Now that the problem has been identified, which action would the nurse do next? -Identify the person responsible for the problem. -Meet with the parties involved to develop a strategy. -Implement the necessary change for the problem. -Revise the focus of the strategy.

-directing staff activities if a client experiences a cardiac arrest

A nurse-manager appropriately behaves as an autocrat in which situation? -planning vacation time for staff -directing staff activities if a client experiences a -cardiac arrest -evaluating a new medication-administration process -identifying the strengths and weaknesses of a client-education video

-directing staff activities if a client experiences a cardiac arrest

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse? -male client who is three days postoperative with an indwelling urinary catheter -female in pelvic traction who is three months pregnant -older adult woman who has been hospitalized for two days with herpes zoster -male admitted for hearing voices commanding him to kill himself

-female in pelvic traction who is three months pregnant

A nurse is caring for a client with cystic fibrosis. With which members of the healthcare team is it most appropriate for the nurse to collaborate? Select all that apply. -nutritional services -physical therapy -social services -occupational therapy -respiratory therapy

-nutritional services -physical therapy -respiratory therapy

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? -teaching a client receiving warfarin about follow-up care -assessing the hip wound during a dry sterile dressing change -obtaining vital signs during blood administration -taking a telephone order for pain medications for a postoperative client

-obtaining vital signs during blood administration

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to -immediately remind the night-shift nurses of the daily calibrations. -arrange a meeting of the day-shift and night-shift nurses. -review the capillary glucose monitoring calibration log book. -counsel the night charge nurse about the discrepancy.

-review the capillary glucose monitoring calibration log book.

What are important nursing responsibilities when a referral to other health team members has been made for a client? -Ensure that the physician reports the level of functioning of the client -recommending that each health team member independently completes an assmt and then consults with each other -recommending that each member read the history and nurse's notes to understand the clients progress -sharing assmt information and information on the client's capability & level of participation in meeting ADL's

-sharing assessment information and information on the client's capability and level of participation in meeting ADL's

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? -encourage activity as tolerated -provide a high-protein, fluid-monitored diet -monitor patient blood pressure. -place the client on a sheepskin, and monitor for increasing edema

-monitor patient blood pressure.

A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? -registered dietitian -PT -OT -nursing assistant

-occupational therapist

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? -create the client assignment by considering available staff's skill level and client needs -refuse to create the client assignment and tell management that a nurse must be found -call charge nurses on other units to request a registered nurse come assist on the unit -notify the local nursing regulating body about the unsafe working conditions at the facility

Create the client assignment by considering available staff's skill level and client needs

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse prepares the client according to the anesthetist's instructions. Which statement by the anesthetist would the nurse question? -"review the client's current medications, and verify the last dose of anticoagulants" -"obtain a set of vital signs, and connect the client to a continuous oxygen saturation monitor" -"position the client supine on the operating table, and prepare the site for injection" -"hold the client firmly in position while I administer the spinal block"

-"Position the client supine on the operating table, and prepare the site for injection."

The nurse is caring for multiple clients on a medical-surgical floor. Which task may the nurse delegate to unlicensed assistive personnel (UAP)? -irrigating a NG tube -assisting a client 3 days post-op to ambulate in the hallway -taking orthostatic blood pressure readings on a client on a new medication -administer an antacid to a client with symptoms of heartburn

-assisting a client 3 days post-op to ambulate in the hallway

A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client indicates to the nurse that the client understands the reasons for home health visits? -"the community health nurse will help fix my meals" -"the community health nurse will give me my antihypertensive medication" -"The community health nurse will check me and my baby and talk with my physician." -"the community health nurse will give me prenatal care so that I won't have to see my physician"

-"The community health nurse will check me and my baby and talk with my physician."

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client? -registered nurse (RN) with 2 years of experience -registered practical nurse/licensed practical or vocational nurse with 5 years of experience -registered nurse who just completed orientation -charge nurse with 10 years of experience

-registered nurse (RN) with 2 years of experience

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? -Create the client assignment by considering available staff's skill level and client needs. -Refuse to create the client assignment and tell management that a nurse must be found. -Call charge nurses on other units to request a registered nurse come assist on the unit. -Notify the local nursing regulating body about the unsafe working conditions at the facility.

-Create the client assignment by considering available staff's skill level and client needs.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? -have UAP keep a steady pull on the client to promote forward ambulation -explain how to overcome a freezing gait by telling the client to march in place -assist the UAP with getting the client back in bed -give the client a muscle relaxant

-Explain how to overcome a freezing gait by telling the client to march in place

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse? -male client who is three days postoperative with indwelling urinary catheter -female in pelvic traction who is three months pregnant -older adult woman who has been hospitalized for two days with herpes zoster -male admitted for hearing voices commanding him to kill himself

-female in pelvic traction who is three months pregnant

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? -Ask the team member what the purpose was in sharing the information. -include the information in report for the next shift -ask the team member what the purpose was in sharing the information -ignore the comment

-Ask the team member what the purpose was in sharing the information.

A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) 2 hours ago. In what order from first to last should the oncoming registered nurse (RN) perform the actions? All options must be used. -Review the prescription for dose and frequency of administration. -Assess the client for pain using a pain scale. -Take the client's vital signs. -Opioid-induced Sedation Scale. -Determine the client's sedation level using the

-Assess the client for pain using a pain scale. -Take the client's vital signs. -Determine the client's sedation level using the Opioid-induced -Sedation Scale. -Review the prescription for dose and frequency of administration.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do? -Require the nurse to do this assignment. -Change the assignment and record the behavior on the nurse's evaluation. -Change the assignment without comment. -Change the assignment to circulate but have the nurse prepare the equipment.

-Change the assignment without comment.

A client with obsessive compulsive disorder reports to the nurse that the routine of having the night-light on was not followed on the night shift. What would be the nurse's best course of action? -document the situation and make an incident report in accordance with hospital protocol -instruct the night nurse to follow the care plan more carefully in the future -place a sign at the end of the bed stating the client needs a night-light -ask the night nurse about the experience of caring for the client the previous night.

-Ask the night nurse about the experience of caring for the client the previous night.

A client diagnosed with cancer of the cervix in situ is scheduled to have a conization. Which is a priority during the 1st 24 postoperative hours? -monitoring vital signs hourly -maintaining strict bed rest -monitoring vaginal bleeding -maintaining electrolyte balance

-monitoring vaginal bleeding

The nurse is caring for a client with inflammatory bowel disease. Which action is appropriate for the nurse to delegate to the nursing assistant? -assistance with ambulation -nasogastric suctioning -continuous pulse oximetry monitoring -patient-controlled analgesia

-assistance with ambulation

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? -8 y/o child admitted that morning with suspected meningitis -9 y/o child receiving subcutaneous insulin for diabetes mellitus -10 y/o child who had a tonsillectomy that morning -9 y/o child with Legg-Calve'-Perthes disease

-9-year-old child receiving subcutaneous insulin for diabetes mellitus

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. -Assess pedal pulses on a client who just returned from a cardiac angiogram. -Administer oxygen via nasal cannula to a client with a saturation of 89%. -Administer acetaminophen to a client with a pain level of "5" out of "10." -Obtain vital signs for a client admitted yesterday. -Obtain intake and outputs on a client experiencing heart failure.

-Obtain vital signs for a client admitted yesterday. -Obtain intake and outputs on a client experiencing heart failure.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? -prescribing adult diapers for the client so she will not have to worry about incontinence -requesting an indwelling urinary catheter to avoid incontinence -padding the bed with extra absorbent linens -placing a commode at the bedside and instructing the client in its use

placing a commode at the bedside and instructing the client in its use

A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do? -insert a foley catheter -start an intravenous infusion -initiate a time-out -verify that the surgeon possesses the degree of expertise needed

-Initiate a time-out

A nurse has been voicing concerns to colleagues about unfair client assignments being assigned by the charge nurse with some nurses consistently having less complex client assignments than others. What action should the charge nurse take upon learning this information? -instruct the nurse to document concerns in writing so the charge nurse can review -assure the staff member that client assignment are made as fair as possible -meet with the nurse privately and provide an opportunity to express concerns -ask the nurse to prove that the assignments are unfair using objective evidence

-Meet with the nurse privately and provide an opportunity to express concerns

During assessment, a client verbally rates pain as 9 out of 10 on a 0-10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next? -notify the HCP that the client is confused and pain is poorly controlled -notify the supervisor that the client did not receive the prescribed pain medication -notify the pharmacist that the client did not receive the prescribed pain medication -approach the nurse who signed for the opioid to seek clarification about the missing drug

-Approach the nurse who signed for the opioid to seek clarification about the missing drug

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? -ask the community health nurse to visit the family -provide written care instructions for the parents -help the parents schedule a follow-up appointment with the pediatrician before discharge -arrange a meeting between the health care team and the parents to develop a care plan

-Arrange a meeting between the health care team and the parents to develop a care plan

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? -rescheduling surgeries -ensuring that clients receiving medications but omitting full bathing when possible -allowing all medications to be given 2 hours late -asking unlicensed assistive personnel (UAPs) to assist in administering analgesics

-ensuring that clients receive medications but omitting full bathing when possible

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit? -a pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV) -a nurse with young children shouldn't care for a neonate whose mother has gonorrhea -a nurse with young children shouldn't care for a neonate with erythema toxicum -a pregnant nurse shouldn't care for a neonate whose mother was positive for HIV

-A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV)

A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads:10/151130The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members. Which priority action must the nurse group leader initiate? -obtain an order for medication to be given every morning -role-play social skills with client before the next group meeting -arrange for a coach to be present with the client at each meeting -formulate an individual contract for appropriate behavior during the group.

-formulate an individual contract for appropriate behavior during the group.

A nurse is assigning the care of a client admitted with appendicitis. The nurse should assign this client's care to: -a licensed practical nurse with pediatric experience -a registered nurse with geriatric experience -a graduate nurse awaiting N-CLEX results -a registered nurse pulled from the cardiac unit.

-a registered nurse pulled from the cardiac unit.

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation? -tell the charge nurse that the statement is hurtful -tell the charge nurse to be more specific about what is meant -the new nurse should discuss feelings with a coworker in order to vent -ask for a private meeting to explore the charge nurse's concerns in detail.

-Ask for a private meeting to explore the charge nurse's concerns in detail.

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first? -assist the client to a stretcher -hold pressure on the fetal head. -take the client to the labor and delivery unit -notify the HCP

-Hold pressure on the fetal head.

A client with obsessive compulsive disorder reports to the nurse that the routine of having the night-light on was not followed on the night shift. What would be the nurse's best course of action? -Document the situation and make an incident report in accordance with hospital protocol. -Instruct the night nurse to follow the care plan more carefully in the future. -Place a sign at the end of the bed stating that the client needs a night-light. -Ask the night nurse about the experience of caring for the client the previous night.

-Ask the night nurse about the experience of caring for the client the previous night.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? -tell the partner to leave because the partner is intimidating the client -question the woman in front of her partner -contact hospital security to escort the partner from the hospital -collaborate with the physician to make a referral to social services.

-Collaborate with the physician to make a referral to social services.

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? -assessment of client restraint location in relation to mental status -evaluation of client response to restraint type -completion of range of motion on limbs restrained -release of restraint as client symptoms improve

-completion of range of motion on limbs restrained

A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan? -identifying nursing goals and explaining the importance of following these goals -discussing collaborative goals and involving the client in identifying and prioritizing important interventions -informing the client of the extent of damage to the liver and drawing up a contract to start rehabilitative process -identifying the potential and actual problems, informing the client about options, and arranging for the client to attend Alcoholics Anonymous

-discussing collaborative goals and involving the client in identifying and prioritizing important interventions

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? -reschedule surgeries -ensuring that clients receive medications but omitting full bathing when possible -allowing all medications to be given 2 hours late -asking unlicensed assistive personnel (UAPs) to assist in administering analgesics

-ensuring that clients receive medications but omitting full bathing when possible

A nurse is planning care for a hospitalized school-age child and is delegating care to a pediatric care assistant. When a nurse delegates a task to an unlicensed assistive personnel (UAP), which factor is most important? -the nurse has observed the UAP perform the task -the child and UAP have established a positive relationship -the task is appropriate for that individual's preparation -the UAP has previously performed the task

-The task is appropriate for that individual's preparation.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? -bacterial vaginitis -gonorrhea -genital herpes -HPV

-gonorrhea

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply. -adult client newly diagnosed with diabetes who is learning to administer insulin -older adult client who had hip replacement surgery and needs to walk in the hall with a walker -adult client who had abdominal surgery yesterday and requires a dressing change -young adult client who requires tube feedings -adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours

-older adult client who had hip replacement surgery and needs to walk in the hall with a walker -adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours

-Which client's care may a registered nurse (RN) safely delegate to the nursing assistant? =a client who requires continuous pulse oximetry monitoring admitted with bronchitis -a client requiring assistance ambulating, who was admitted with a history of seizures -a client with a trach that requires intermittent suctioning -a client with end-stage chronic obstructive pulmonary disease receiving patient-controlled analgesia.

-a client requiring assistance ambulating, who was admitted with a history of seizures

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? -"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." -"The continuous passive motion device can decrease the development of adhesions." -"Bleeding is a complication associated with the continuous passive motion device." -"Monitoring skin integrity is important while the continuous passive motion device is in place."

-"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? -Tell the ICU they have to wait to transfer the client because everyone is too busy to accept the client. -Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the

-Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do? -increase the amount of iron in the client's diet -apply lotion to the lower extremities -elevate the legs -consult the health care provider.

-consult the health care provider

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? -providing passive range of motion exercises to the left extremities during the bed bath -elevating the foot of the bed to reduce edema -pulling up the client under the left shoulder when getting the client out of bed to a chair -putting high top tennis shoes on the client after bathing

-pulling up the client under the left shoulder when getting the client out of bed to a chair

A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take? -receive the prescription over the phone and repeat it back to the HCP to verify accuracy -request the HCP text the prescription via mobile phone to reduce the risk of misinterpretation -reinforce that all client prescriptions must be entered directly by the HCP into the EHR -ask the charge nurse to receive the telephone prescription from the HCP

-receive the prescription over the phone and repeat it back to the HCP to verify accuracy

A nurse who is a case manager is responsible for assigning client care to unlicensed assistive personnel (UAPs). The nurse is planning the care for a new pediatric client who requires several treatments. Which UAP will the nurse assign to care for the new client? -the UAP who has independently provided the same treatments to clients in the past -the UAP who has had supervised practice with all of the required treatments -the UAP who is friendliest with the children on the unit -the UAP with the best time management and organization skills

-the UAP who has independently provided the same treatments to clients in the past

The charge nurse is preparing for the day shift on the labor and birth unit. What would be included in the responsibilities for this position? Select all that apply. -Review the current status of each labor client with the primary nurse. -Admit the new labor client sent from the triage area. -Complete the work of the nurse who had to leave 30 minutes early. -Follow up with the primary nurse after a birth. -Complete the unit report with the oncoming charge nurse.

-Review the current status of each labor client with the primary nurse. -Follow up with the primary nurse after a birth. -Complete the unit report with the oncoming charge nurse.

A registered nurse (RN) is assigning tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the client care team. Which task is restricted in terms of which care team member it could be delegated to? Select all that apply. -assisting a client to the bathroom who uses a walker for mobility -providing oral care to a client who had nothing by mouth before surgery -administering oral pain medication to a postoperative client -assessing a client who just returned from cardiac catheterization -taking the health history of a newly admitted client

-administering oral pain medication to a postoperative client -assessing a client who just returned from cardiac catheterization -taking the health history of a newly admitted client

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? -Explain to the primary nurse that a 6-week orientation is standard. -Meet with the new nurse and the primary nurse and help set up an additional week of orientation. -Meet with the new nurse and question the new nurse about deficits in performance. -Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process.

-a client requiring assistance ambulating, who was admitted with a history of seizures

A clinical nurse specialist developed clinical pathways for common orthopedic conditions. In which way should the interdisciplinary team use these pathways? -as guidelines to ensure continuity of care -as a step-by-step care plan for clients -as a way to accurately document care -as a staff education tool about optimal care

-as guidelines to ensure continuity of care

The nurse is preparing to provide details on a client to the healthcare team coming on duty for the next shift. Which form of communication should the nurse use to best enhance a safe transfer of care? -written report -audio recorded report -group report -bedside report

-bedside report

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which effect is the most important to report to the physician? -increased temperature and metabolic rate -insomnia and loss of weight -increased energy level and reduction of edema -palpitations and chest pain on exertion

-palpitations and chest pain on exertion

Which task(s) would a nurse choose to delegate to an unlicensed assistive personnel (UAP)? Select all that apply. -planning bathing techniques -taking a client's vital signs -documenting a client's oral intake -performing a blood glucose check -assisting with I.V. insertion

-taking a client's vital signs -documenting a client's oral intake -performing a blood glucose check -assisting with I.V. insertion