HESI COMP 2 x

The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.) Correct 0. Clamp the drainage tubing. 1. Label the urine specimen. 2. Place in a biohazard bag. 3. Document the procedure.

1) The drainage tubing should be clamped before obtaining the specimen. After withdrawing the urine specimen, 2) the specimen is labeled, and then 3) the container is placed in a biohazard bag for transport to the laboratory. 4) Documentation should be completed after the specimen is labeled and transported to the laboratory. Category: Fundamentals

A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? A. Place the client in mechanical restraints until calm. Correct B. Administer a PRN dose of haloperidol (Haldol) IM. C. Use a calm, soothing voice to diffuse the situation. D. Encourage the client to focus on his feelings of anger.

A This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member (A). (B) may pose a danger to the staff. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to (C) or have the ability to verbalize his feelings (D). Category: Psychiatric Mental Health

A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? A. Encourage the student to associate with non-smokers only while attempting to stop smoking. Correct B. Tell the student that he is still young and should continue to try various smoking cessation methods. C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. D. Provide the student with the latest research data describing the long-term effects of tobacco use.

A. It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers, so (A) is the most important intervention for the nurse to implement. (B) is not likely to be helpful and offers no concrete suggestions for smoking cessation. (C) is condescending. Risks associated with smoking must already be known to this adolescent who is already attempting to stop the habit (D). Category: Fundamentals

While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? A. Continue the interview process and record the findings. Correct B. Refer the client to a psychiatric outpatient clinic. C. Determine if there is a family history of emotional disorders. D. Encourage the woman to attend citizenship classes.

A. The nurse should accept these behaviors as culturally determined and continue with the interview (A). These behaviors are common in the Chinese culture where people are members of strong, cohesive groups that focus on the group rather than the individual. These behaviors are not related to a psychiatric disorder (B and C). Citizenship (D) is an individual choice, while cultural behaviors evolve over time. Category: Fundamentals

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? A. Record these findings in the client's record. Correct B. Observe closely for possible dehiscence. C. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. D. Increase the IV fluid rate and encourage the client to eat more ice chips.

A. These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention (A). Dehiscence (B) is separation of a surgical incision, and there is no indication that this is a possibility at this time. Serosanguineous drainage is thin and red and is composed of serum and blood, and this client is not exhibiting this finding, and even if the wound was producing this drainage, the finding does not warrant (C). There is no indication of dehydration, so (D) is not indicated at this time. Category: Fundamentals

A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? A Level of fetal lung maturity. B. Presence of genetic disorders. Correct C. Quantification of alpha-fetoprotein levels. D. Determination of gestational age.

B Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal, genetic, and metabolic disorders (B). Amniocentesis in the third trimester assesses fetal lung maturity (A) by evaluating the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels (C) after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks ) are found. While specific levels of creatinine, bilirubin, and lipid cells are present in amniotic fluid only after 35 to 36 weeks gestation, gestational age (D) is commonly evaluated by ultrasound. Category: Maternity

Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? A. Improve the client's body perception. B. Consume at least 50% of all meals. Correct C. Exercise no more than one hour daily. D. 5% decrease in serum potassium levels.

B An outcome statement should be measurable and provide observable behaviors that indicate the client's problem is resolving. Self-starvation is the major problem associated with anorexia nervosa, so (B) should be included in this client's plan of care. (A) is vague and not measurable. Adolescents with anorexia nervosa often obsessively exercise to lose additional weight, so (C) may be excessive. Clients with anorexia have an increased risk for hypokalemia, so (D) is an inappropriate goal for this client. Category: Psychiatric Mental Health

While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? A. Unexplained weight gain. B. Current hair care practices. Correct C. Family history of alopecia. D. Absence of axillary hair.

B Dry and brittle hair may be a result of hair treatments such as hair dyes, rinses, permanents, straighteners, or frequent blow-drying (B). Although an unexplained weight gain (A) could be related to hypothyroidism, which causes hair to become dry and brittle, assessing current hair care practices should be determined first because of the prevalent use of cosmetic products. Next, a family history of alopecia (C) and absence of axillary hair (D) should be assessed to identify other problems contributing to hair abnormalities, such as nutritional deficiencies, endocrine dysfunction, or genetic predisposition. Category: Medical-Surgical

To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? A. Review the client's fasting blood glucose levels for a hyperglycemic trend. B. Determine if the client has ever had a hypersensitivity reaction to penicillins. Correct C. Restrict the use of dairy products in the client's diet for the next 3 weeks. D. Take the client's vital signs prior to the first dose and once daily for 14 days.

B Most individuals who have an allergy to penicillins (B) are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Ceclor) dose. (A, C, and D) are not required interventions for the administration of cephalexin (Ceclor). Category: Pharmacology

An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority? A. Call for the emergency resuscitation team and retrieve the unit's crash cart. B. Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. Correct C. Observe the client's trunk and back for any hives and ask about the onset of urticaria. D. Notify the healthcare provider and prepare to administer IV diphenhydramine (Benadryl).

B The client's symptoms depict the onset of an anaphylactic reaction to ticarcillin, an extended-spectrum penicillin, so the priority nursing actions include halting the client's exposure to the medication and supporting breathing efforts (B). (A, C, and D) are important interventions that should occur immediately after (B) is implemented. Category: Pharmacology

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? A. Collect blood for hemoglobin and hematocrit. B. Start the first transfusion of blood. Correct C. Insert an indwelling urinary catheter. D. Encourage alternate rest periods with activity.

B The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started (B). (A) should be obtained after the client is transfused to evaluate its effectiveness. (C) is not indicated at this time. (D) should be included in the plan of care, but is not as essential as (B) at this time. Category: Medical-Surgical

Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? A. African-American women who are 30 to 35 years of age. B. Survivors of violence that occurred at least 5 years ago. Correct C. Active armed forces reserve unit returning from Europe. D. Full-time students who are attending public colleges.

B. Vulnerable populations are those groups who have an increased risk of developing adverse health outcomes. Survivors of violence (B), even though the violence occurred more than 5 years ago, have an increased risk for adverse health outcomes. (A, C, and D) describe demographic groups. Category: Community Health

The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.) Correct 0. Measure the client's vital signs. 1. Review medications client is taking. 2. Notify the healthcare provider. 3. Complete an incident report.

Cardizem is a calcium channel blocker that decreases blood pressure, and slows SA or AV node conduction, which can cause bradycardia or cardiac arrhythmias, so 1) the client's vital signs should be measured first to determine the client's reaction to the medication error. 2) The client's current medications should be reviewed before 3) notifying the healthcare provider, and then 4) the incident report completed. Category: Management

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? A. Replace the empty tank without reporting the situation to any members of the agency. B. Complete an adverse occurrence report and submit it to the nurse-manager. Correct C. Send an anonymous letter explaining the situation to the family of the client. D. Advise the flight crew of the situation, then suggest that no further discussion be held.

B. A medication error occurred, so an adverse occurrence report should be completed and submitted to the nurse-manager (B) for evaluation of the situation, so that measures can be implemented to prevent a repeat of the occurrence. (A, C, and D) do not allow for review of the system to prevent a repeat of the occurrence. Category: Fundamentals

Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? A. Promote hygiene by ensuring that children's faces and hair are kept clean. B. Ensure that all enrolled children have been immunized for Hepatitis A. Correct C. Put a strip bandage on bleeding injuries to prevent contamination of others. D. Teach children the correct handwashing technique to use after toileting.

B. The CDC recommended immunization schedule for children includes the hepatitis A vaccine (HAV), so follow-up of enrolled children's immunization status with HAV or human-immune gamma globulin should be implemented (B). Preschoolers should be taught the importance of hygiene practices, such as (A and D), but hepatitis A is transmitted via the fecal-oral route and immunization provides the best universal protection. Hepatitis A is not transmitted through blood contact (C). Category: Community Health

The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? A . Counsel the UAP about the inaccurate blood pressure readings. B. Observe the UAP performing blood pressure measurements. Correct C. Make staff members aware of the possible errors in blood pressure readings. D Ask the education department to provide additional training for the UAP.

B. The charge nurse should first observe the UAP's performance (B), then take appropriate action, which might include (A, C and D). Category: Management

A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? A. Nurses use their best judgment based on the client's condition. B. The healthcare team must honor the written wishes of the client. Correct C. Notify the healthcare provider of the family's wishes, so a decision can be made. D. Every effort must be made to honor the family's wishes about their loved one.

B. The client (B) should be the ultimate decision-maker regarding treatment or refusal of treatment. The client's ethical right to autonomy and legal right to give informed consent for treatment are recognized in both legally created special directives and living wills. Although family members are very important in the care and support of the client, the nurse (A), and healthcare provider (C) must respect the legal document that the client created to direct the course of treatment (D). Category: Fundamentals

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? A. Page the unit manager to address the situation. B. Close the demographic screen on the computer. Correct C. Instruct the UAP to end the phone call immediately. D. Send a UAP into the client's room to relieve the nurse.

B. The greatest priority is for the charge nurse to close the computer screen (B), because health information stored in computerized systems is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act). (A, C, and D) may be indicated, but are of less priority than (B). Category: Fundamentals

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? A . Hand washing prior to preparation of the injection. B. Method used to aspirate medication from a vial. Correct C. Selection and rotation of injection sites. D. Proper disposal of injection equipment.

B. To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration (B). (A, C, and D) are teaching topics, but are not components of maintaining sterile technique while administering an injection. Category: Fundamentals

A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? A. Ask the parents to participate in encouraging the child's fluid intake. B. Tell the child he can go outside after he drinks a full glass of water. C. Offer the child a popsicle and allow him to pick the flavor he prefers. Correct D. Make a game of seeing who can finish a glass of water first--the nurse or the child.

C Fluids in popsicle form (C) are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. (A) is a good intervention, but (C) is better. (B) is manipulative and the nurse must be careful not to make promises that may not be possible. Although (D) may be useful, it may also be manipulative and is not as likely as (C) to obtain the ultimate goal of increasing fluids. Category: Pediatrics

About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? A. A chocolate bar. B. A soft drink. C. Peanut butter crackers. Correct D. A piece of bubble gum.

C Peanut butter crackers (C) provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously. (A, B, and D) contain only simple sugars. Category: Pediatrics

During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement? A. Prepare a written schedule to remind the client when to take each dose of aspirin. B. Observe the client place each dose in the correct boxes of her pill container. C. Contact the client's healthcare provider to report the assessment findings. Correct D. Ask a family member to ensure that the client takes the medication as prescribed.

C Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of aspirin that the client is taking. The healthcare provider should be notified of the symptoms (C) to determine further treatment. (A, B, and D) are likely to increase the client's symptoms of toxicity. Category: Pharmacology

A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? A . Deep tendon reflexes 1+. B. Blood pressure of 140/90. C. Respirations of 10. Correct D Urinary output of 130 ml in 4 hours.

C With respirations less than 12 (C), the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours (or 25 ml/hour) (D) and absent reflexes. Reflexes of 1+ (A) are hypoactive but present. A client with preeclampsia can seize with blood pressures lower than 140/90 (B). Magnesium sulfate is not an antihypertensive. Category: Maternity

Which action should the nurse take first when performing tracheostomy care? A. Cleanse around the stoma. B. Suction the tracheostomy. C. Oxygenate with 100% oxygen. Correct D. Secure the new neck strap. Hyperinflation with 100% oxygen (C) helps minimize hypoxia and atelectasis during the suctioning procedure, so the nurse should take this action first, before (A, B, or D). Category: Fundamentals

C.

The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? A. Document the change in pulse rate on the graphics sheet. B. Review the client's medical history for cardiac problems. C. Reassess the rate and characteristics of the client's pulse. Correct D. Ask the UAP to recheck the client's pulse in thirty minutes.

C. A change in heart rate or rhythm reflects a change in physiologic homeostasis that may be potentially life threatening, so it is most important to immediately reassess the client's pulse rate and characteristics (C). After reassessing the client, the nurse should document the findings (A), review the client's medical record for related history (B), and determine further needed intervention, such as rechecking the client's vital signs (D). Category: Fundamentals

When culturing a wound, the nurse should obtain the sample from which part of the wound? A. The outer edges of the wound. B. All necrotic sections of the wound. C. Areas containing purulent or pooled exudates. Correct D. Any particularly painful area of the wound.

C. To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions (C), then return the swab to the culturette tube, cap the tube, and crush the inner ampoule so that the medium for the organism growth coats the swab. The culture should not be collected from (A, B, or D). Category: Fundamentals

The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged? A. Review the client's most recent serum calcium level. B. Verify that the crutches fit snugly under the axilla. C. Observe the client while demonstrating crutch walking. Correct D Determine if the client lives alone or with others.

C. To evaluate a client's ability to crutch walk, the nurse should observe the client perform the skill (C). It is not necessary to check the client's serum calcium level (A). Crutches should be two to three inches from the axilla (B) to prevent brachial plexus damage. Living alone (D) should not be a problem because the client can use the three point gait with the crutches to perform self-care. Category: Fundamentals

When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? A. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. B. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. C. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. D. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. Correct

D A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs (D). (A, B, and C) provide useful information about teething, but do not have the priority of (D). Category: Pediatrics

An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone (Deltasone). The nurse should teach the child to check his urine for which finding? A. White blood cells. B. Glucose. C. Ketones. D. Protein. Correct

D Children should be taught to check for protein (albumin) (D) in the urine daily, because a positive reading for protein in the urine is often the only indicator of a relapse of nephrotic syndrome. (A) is an indication of infection. (B and C) should be assessed while the child is receiving corticosteroid therapy, since corticosteroids increase blood glucose. Category: Pediatrics

While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? A. Notify respiratory therapy immediately for a PRN bronchodilator treatment. B. Obtain a prescription to increase the tidal volume setting on the ventilator. C. Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. D. Suction the client's endotracheal tube and auscultate following suctioning. Correct

D Coarse, snoring sounds (rhonchi) heard over large upper airways are frequently produced by secretions partially blocking air passages and usually disappear after suctioning (D). (A) is indicated for a bronchospasm, which typically produces wheezing or musical adventitious lung sounds. Increasing the tidal volume (B) does not help resolve the problem. Mechanical ventilators produce noise that makes lung auscultation difficult, but removal of the ventilator to listen to breath sounds (C) is contraindicated, as this may reduce oxygenation. Category: Medical-Surgical

Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? A. Assess the client's current oxygen saturation level. B. Auscultate the client's breath sounds bilaterally. C. Prepare to administer a dose of naloxone (Narcan) IV. D. Attempt to arouse the client to stimulate respirations. Correct

D The nurse should first attempt to stimulate respirations by arousing the client (D). This measure is noninvasive and may produce an immediate increase in respiratory rate. If this action is unsuccessful, the nurse should then implement (A, B, and C). Category: Pharmacology

A male client who is two days postoperative for a bowel resection moves as little as possible and does not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it out." What response is best for the nurse to provide? A. Side effects are not a concern because they usually decrease over time. B. Very few clients become addicted to opioids when using them for pain control. C. There are multiple options of medications that can be offered if one drug does not relieve the pain. D. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery. Correct

D Unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate, cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased catabolism (D). (A, B, and C) do not give the client sufficient information to ensure compliance with the postoperative plan of care. Category: Medical-Surgical

The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN? A . A client receiving Lactated Ringer's solution requests pain medication. B. A client with a history of falls needs assistance to the bathroom. C. A client's indwelling urinary catheter requires manual irrigation. D. A client with an epidural infusion reports lower extremity parasthesia. Correct

D. Assessment of possible adverse effects of an epidural infusion (D) should be performed by the RN, who has the expertise to evaluate the significance of the assessment data. (A, B, and C) are skills that can be delegated to the PN. Category: Management

A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? A. Write the correct prescription as a verbal order received from the healthcare provider. B. Correct the misspelled medication in the written prescription and initial the change. C. Consult with the pharmacist to determine the best medication for the client. D. Contact the healthcare provider to clarify the prescription intended for the client. Correct

D. Since the nurse received contradictory information, the provider should be contacted (D) to clarify the intended prescription. (A) may result in a medication error. The nurse does not have the authority to alter prescriptions (B). The pharmacist (C) cannot determine the best medication for a client. Category: Fundamentals

A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? A . Dismiss the staff nurse's report about the float nurse because it may be just gossip. B. Call the nursing supervisor and request a different employee be sent to the unit. C. Assign the float nurse to function as a UAP for the day. D. Arrange for someone to be available to assess and assist the float nurse. Correct

D. The float nurse is receiving education, but careful assessment of her/his skills and assistance, as needed, is still warranted, so (D) is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information could constitute negligence on the part of the charge nurse (A). (B) is not the best way to manage the unit. (C) is not the best use of a licensed person, and would also eliminate the float nurse's opportunity to improve medication administration skills. Category: Management

A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) Correct 1. Airway and breathing. 2. Pain management. 3. Sleep and rest. 4. Definitive therapy.

First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies. Category: Fundamentals

The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) Correct 0. Raise bed to a comfortable working height. 1. Lower the side rail between the nurse and the client. 2. Position the client in a flat side-lying position. 3. Place an emesis basin under the client's chin.

To ensure client and nurse safety when performing oral care for an unconscious client, first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin. Category: Fundamentals