Leadership Final

The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

2. The first action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs' behavior in public

The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess? 1. Why the client did not have a viable baby with the first pregnancy. 2. If the mother received a Rhogam injection after the last pregnancy. 3. The period of time between the client's pregnancies. 4. When the mother terminated the previous pregnancy

2. The important information to assess is whether the client received the Rhogam injection within 72 hours of the loss of the first pregnancy. If the client did not receive the injection, the fetus is at risk for erythroblastosis fetalis (blue baby).

The 65-year-old client is being discharged from the hospital following major abdominal surgery and is unable to drive. Which referral should the nurse make to ensure continuity of care? 1. A church that can provide transportation. 2. A home health agency. 3. An outpatient clinic. 4. The healthcare provider's office

2. The nurse should refer the client to a home health agency for follow-up care. The nurse will go to the client's home to assess the client and perform dressing changes. The home health agency will also assess the client and the client's home for further needs.

Which action by the nurse is a violation of the Joint Commission's Patient Safety Goals? 1. The surgery nurse calls a time-out when a discrepancy is noted on the surgical permit. 2. The unit nurse asks the client for his or her date of birth before administering medications. 3. The nurse educator gives the orientee the answers to the quiz covering the IV pumps. 4. The admitting nurse initiates the facility's fall prevention program on an older adult client.

3. A quiz during orientation is given to assess whether the new employee understands the information being taught. Giving the answers to the quiz completes the required documentation for the employee's files but does not ensure the new hire understands how to utilize the IV pump. This is a violation of the Patient Safety Goals

The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? 1. Apply a sterile dressing to a Stage IV pressure wound. 2. Check the blood glucose level of a resident who is weak and shaky. 3. Document the amount of food the residents ate after a meal. 4. Teach the residents how to play different types of bingo.

3. The UAP can check to see the amount of food the residents consumed and document the information.

The charge nurse must notify a staff member to stay home because of low census. The unit currently has 35 clients who all have at least one IV and multiple IV medications. The unit is staffed with two RNs, three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which nurse should be notified to stay home? 1. The least experienced RN. 2. The most experienced LPN. 3. The UAP who asked to be requested off. 4. The UAP who was hired 4 weeks ago.

3. The UAP cannot administer medications or IVs and has requested to be allowed to stay home. This is the best staff member to request to stay home.

Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis? 1. The client's serum creatinine level is 2.4 mg/dL. 2. The client's abdomen is soft to touch and nontender. 3. The dialysate being removed from the abdomen is cloudy. 4. The dialysate instilled was 1,500 mL and removed was 2,100 mL.

3. The dialysate return should be colorless or straw colored but should never be cloudy, which indicates an infection; therefore, the data warrant immediate intervention.

The nurse manager of the maternal-child department is developing the budget for the next fiscal year. Which statement best explains the first step of the budgetary process? 1. Ask the staff for input about needed equipment. 2. Assess any new department project for costs. 3. Review the department's current year budget. 4. Explain the new budget requirements to the staff.

3. The first step in a budgetary process is to assess the current budget.

The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualified. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

3. The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care.

The nurse on the psychiatric unit observes one client shove another client. Which intervention should the nurse implement first? 1. Discuss the aggressive behavior with the client. 2. Document the occurrence in the client's chart. 3. Approach the client with another staff member. 4. Instruct the client to go to the unit's quiet room.

3. The nurse should intervene to stop the behavior first before one of the clients is injured. Approaching the client with another staff member shows strength and provides the nurse with the ability to perform a safe "take down."

The unlicensed assistive personnel (UAP) is changing a full sharps container in the client's room. Which action should the nurse implement? 1. Tell the UAP she cannot change the sharps container. 2. Explain the housekeeping department changes the sharps containers. 3. Praise the UAP for taking the initiative to change the sharps container. 4. Report the behavior to the clinical manager on the unit.

3. The nurse should reward appropriate behavior by the other healthcare members.Verbal praise is always appreciated by anyone.

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. 2. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. 3. The client with renal calculi who is complaining of severe flank pain and has hematuria. 4. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia

3. The nurse would not expect the client with renal calculi to have blood in the urine (hematuria) and the pain should not be severe; therefore, this client should be assessed to determine if the client is having complications.

The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client's condition. Which information should the nurse discuss with the volunteer? 1. Determine how well she knows the client before talking with the volunteer. 2. Tell the volunteer the client's condition in layperson's terms. 3. Ask the client if it is all right to talk with the volunteer. 4. Explain that client information is on a need-to-know basis only.

4. The nurse should remind the volunteer of the HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting

The newborn nursery nurse has received report. Which client should the nurse assess first? 1. The 2-hour-old infant who has nasal flaring and is grunting. 2. The 6-hour-old infant who has not passed meconium stool. 3. The 12-hour-old infant who refuses to latch onto the breast. 4. The 24-hour-old infant who has a positive startle reflex.

1. Nasal flaring and grunting indicate the infant is in respiratory distress. The nurse should assess this infant first.

Which statement best describes the role of the parish nurse? 1. The parish nurse practices holistic healthcare within a faith community. 2. The parish nurse cares for clients in a religious-based hospital. 3. The parish nurse practices nursing in a parish clinic. 4. The parish nurse is a licensed practical nurse (LPN) who cares for clients in the home.

1. Parish nursing emphasizes the relationship between spiritual faith and health. A parish nurse (PN) is a registered nurse with a minimum of 2 years' experience who works in a faith community to address health issues of its members as well as those in the broader community or neighborhood.

The chief nursing officer (CNO) of an extended care facility is attending shift report with two charge nurses, and an argument about a resident's care ensues. Which action should the CNO implement first? 1. Ask the two charge nurses to stop arguing and go to a private area. 2. Listen to both sides of the argument and then implement a plan of care. 3. Ask the family to join the discussion before deciding how to implement care. 4. Tell the nurses to stop arguing and continue to give report.

2. The CNO should evaluate the concerns of each charge nurse and then make a decision as to a plan of care for the resident. The CNO is the next in command over the charge nurses in an extended care facility.

The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? 1. It guarantees that unions will not be able to come into the hospital. 2. It makes the manager responsible for sharing information with the staff. 3. It involves staff nurses in the decision-making process of the unit. 4. It is a system used to represent the nurses in labor disputes.

3. Shared governance is an organizational framework in which the nurse has autonomy over his or her own practice. The nurse is given direct input into the working of the unit.

The clinic nurse is reviewing the laboratory data of clients seen in the clinic the previous day. Which client requires immediate intervention by the nurse? 1. The client whose white blood cell (WBC) count is 9.5 mm3. 2. The client whose cholesterol level is 230 mg/dL. 3. The client whose calcium level is 10.4 mg/dL. 4. The client whose International Normalized Ratio (INR) is 3.8.

4. The therapeutic range for an INR is 2 to 3.This client is at risk for bleeding and requires immediate intervention by the nurse. The nurse should call the client and instruct the client to stop taking warfarin (Coumadin), an anticoagulant.

The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound. 2. Keep the resident's heels off the surface of the bed. 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake

1. Wound debriding formulations are medications, and a UAP cannot administer medications.

Which statement is an example of community-oriented, population-focused nursing? 1. The nurse cares for an older adult client who had a kidney transplant and who lives in the community. 2. The nurse develops an educational program for the type 2 diabetics in the community. 3. The nurse refers a client with Cushing's syndrome to the registered dietician. 4. The nurse provides the client chronic renal disease with pamphlets.

2. Community-oriented, population-focused nursing practice involves the engagement of nursing in promoting and protecting the health of populations, not individuals in the community. Therefore, this is an example of community-oriented, populationfocused nursing.

The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1? 1. The client with head trauma whose pupils are fixed and dilated. 2. The client with compound fractures of the tibia and fibula. 3. The client with a sprained right wrist with a 1-inch laceration. 4. The client with a piece of metal embedded in the right eye.

2. This client should be categorized as red, priority 1, which means the injury is life threatening but survivable with minimal intervention. These clients can deteriorate rapidly without treatment.

The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first? 1. Discuss the disaster situation with the media. 2. Write the client's name clearly in the disaster log. 3. Place disaster tags securely on the victims. 4. Identify an area for family members to wait.

3. Client tracking is a critical component of casualty management. Disaster tags, which include name, address, age, location, description of injuries, and treatments or medications administered, must be securely attached to the client.

The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement? 1. Ask the UAP to take the client's vital signs. 2. Request the UAP to log roll the client to the right side. 3. Complete the neurovascular assessment on the client's legs. 4. Contact the physical therapist to check the client

3. The nurse should assess the client whenever receiving any information from another member of the healthcare team.

The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. 1. Teach the parent about weighing diapers to determine output status. 2. Show the parent the call light and explain safety regimens. 3. Assess the toddler's tissue turgor. 4. Place the appropriate size diapers in the room. 5. Take the toddler's vital signs.

5, 3, 2, 4, 1

The 36-year-old client in the women's health clinic is being prescribed birth control pills. Which information is important for the nurse to teach the client? Select all that apply. 1. Do not smoke while taking birth control pills. 2. Take one pill at the same time every day. 3. If a birth control pill is missed, do not double up. 4. Stop taking the pill if breakthrough bleeding occurs. 5. There can be interactions with other medications.

1, 2, and 5 are correct

The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? 1. Systems that make it difficult for the nurses to do their job. 2. How unhappy the nurses are with their current pay scale. 3. Collective bargaining activity at a nearby hospital. 4. The number of medication errors committed by an individual nurse.

1. A quality improvement project looks at the way tasks are performed and attempts to see whether the system can be improved. A medication delivery system in which it takes a long time for the nurse to receive a STAT or "now" medication is an example of a system that needs improvement, and should be addressed by a quality improvement committee.

The psychiatric nurse and mental health worker (MHW) on a psychiatric unit are caring for a group of clients. Which nursing task should the nurse delegate to the MHW? 1. Take the school-aged children to the on-campus classroom. 2. Lead a group therapy session on behavior control. 3. Explain the purpose of recreation therapy to the client. 4. Give a bipolar client a bed bath and shampoo the hair.

1. Pediatric clients in a psychiatric facility must keep up with schoolwork. Clients must be escorted from one building to another. The MHW should be assigned to this task.

The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? 1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. 2. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau's sign.

1. The Glasgow Coma Scale ranges from 0 to 15, with 15 indicating the client's neurological status is intact. A Glasgow Coma Scale score of 13 indicates the client is stable and would be the most appropriate client to assign to the graduate nurse.

The charge nurse in an extended care facility notes an elderly male resident holding hands with an elderly female resident. Which intervention should the charge nurse implement? 1. Do nothing, because this is a natural human need. 2. Notify the family of the residents about the situation. 3. Separate the residents for all activities. 4. Call a care plan meeting with other staff members

1. The charge nurse does not have a right to interfere with two consenting adults having a relationship. Doing nothing is the correct action for the charge nurse. If one of the residents involved is incapable of giving consent to a relationship, then the charge nurse would need to get involved.

The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first? 1. Determine whether the client has grab bars in the bathroom. 2. Encourage the client to take a shower instead of a bath. 3. Initiate a referral to a physical therapist for the client. 4. Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

1. The first intervention is for the nurse to ensure the client is safe in the home. Assessing for grab bars in the bathroom is addressing the safety of the client.

The labor and delivery nurse has assisted in the delivery of a 37-week fetal demise. Which intervention should the nurse implement? 1. Remove the baby from the delivery area quickly. 2. Tell the father to arrange to take the infant home. 3. Wrap the infant in a towel and place it aside. 4. Obtain a lock of the infant's hair for the parents.

1. The mother may want to see her infant before the body is removed from the room. 4. The nurse can present the parents with a lock of the infant's hair and a set of footprints. Giving the parents something of the infant helps with the grieving process.

The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider

1. The nurse should first assess the client prior to taking any other action to determine if the client is experiencing any untoward reaction.

The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the licensed practical nurse (LPN)? 1. The 6-year-old client diagnosed with sickle cell crisis. 2. The 8-year-old client diagnosed with biliary atresia. 3. The 10-year-old client diagnosed with anaphylaxis. 4. The 11-year-old client diagnosed with pneumonia.

4. The LPN can administer routine medications and care for clients who have no life-threatening conditions

The 32-year-old male client with a traumatic right above-the-elbow amputation tells the home health (HH) nurse he is worried about supporting his family and finding employment since he can't be a mechanic anymore. Which intervention should the nurse implement? 1. Contact the HH agency's occupational therapist. 2. Refer the client to the state rehabilitation commission. 3. Ask the HH agency's social worker about disability. 4. Suggest he talk to his wife about his concerns.

2. The NCLEX-RN® test blueprint lists referrals under Management of Care. After a client has been injured and is unable to return to previous employment because of the injury, the rehabilitation commission of each state will help evaluate the client and determine whether the client is eligible to receive training or education for another occupation.

Which data indicates therapy has been effective for the client diagnosed with bipolar disorder? 1. The client only has four episodes of mania in 6 months. 2. The client goes to work every day for 9 months. 3. The client wears a nightgown to the day room for therapy. 4. The client has had three motor vehicle accidents.

2. The ability to hold a job for 9 months indicates the client is responding to therapy.

The HH aide calls the HH nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Visit the client to assess the reddened area. 3. Document the finding in the client's chart. 4. Refer the client to the wound care nurse.

2. The nurse must first assess the reddened area to determine the stage of the pressure ulcer and what treatment should be recommended.

The nurse is caring for a female client 3 days post-knee replacement surgery when the client complains of vaginal itching. The medication administration report (MAR) indicates the client has been receiving the antacid calcium carbonate (Maalox), the antibiotic ceftriaxone (Rocephin), and the anticoagulant enoxaparin (Lovenox). Which priority intervention should the nurse implement? 1. Request the dietary department to send yogurt on each tray. 2. Explain to the client this is the result of the antibiotic therapy. 3. Notify the HCP on rounds of the client's vaginal itching. 4. Ask the client whether she is having unprotected sexual activity.

2. The nurse should first explain to the client that this is a side effect of the antibiotic medication. Then, the nurse should notify the dietitian and HCP. The antibiotic therapy cannot be discontinued because of the need for antibiotic therapy after knee replacement surgery

The psychiatric clinic nurse is returning telephone calls. Which telephone call should the nurse return first? 1. The female client who reports being slapped by her husband when he got drunk last night. 2. The male client who reports he is tired of living, since his wife just left him because he lost his job. 3. The female client diagnosed with anorexia who reports she does not think she can stand to eat today. 4. The male client diagnosed with Parkinson's disease who reports his hands are shaking more than yesterday

2. The nurse should return this call first because the nurse must determine whether the client has a plan for suicide.

The nurse is taking a history on a client in a women's clinic when the client tells the nurse, "I have been trying to get pregnant for 3 years." Which question is the nurse's best response? 1. "How many attempts have you made to get pregnant?" 2. "What have you tried to help you get pregnant?" 3. "Does your insurance cover infertility treatments?" 4. "Have you considered adoption as an option?"

2. This is the best question to assess the client. The nurse would not want to suggest an intervention that has been futile.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

4. The UAP can add up the urine output for the 12-hour shift; however, the nurse is responsible for evaluating whether the urine output is what is expected for the client.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP? 1. Sit with the 6-year-old client while the parent goes outside to smoke. 2. Stay with the 4-year-old client during scheduled play therapy sessions. 3. Position the 2-year-old client for the postural drainage therapy. 4. Weigh the diaper of the 6-month-old client who is on intake and output (I&O).

4. The UAP is capable of completing intake and output on clients. Weighing a diaper is the method of obtaining the output in an infant.

Which client should the charge nurse of a long-term care facility see first after receiving shift report? 1. The client who is unhappy about being placed in a long-term care facility. 2. The client who wants to have the HCP to order a nightly glass of wine. 3. The client who is upset because the call light was not answered for 30 minutes. 4. The client whose son is being discharged from the hospital after heart surgery.

3. This client may or may not have a valid complaint. The nurse should investigate whether or not the complaint is true. Failure to answer a call light can result in the client's attempting to ambulate without assistance and could be a safety issue. The nurse should speak with this client first.

The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first? 1. Document the findings in the client's chart. 2. Elevate the client's right hand. 3. Assess the radial pulse with the Doppler. 4. Notify the client's healthcare provider.

4. The client is exhibiting severe neurovascular compromise, which indicates a surgical complication and requires notifying the surgeon immediately

The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit? 1. Send the unlicensed assistive personnel (UAP) who has worked on the surgical unit for 5 years. 2. Send the RN who has worked in the hospital for 8 years in a variety of areas. 3. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit. 4. Send the new graduate nurse who is orienting to the surgical unit.

3. The LPN would be the most appropriate staff to send to the medical unit because the LPN has experience on the unit. His or her expertise is also not required to perform custodial care.

The nurse in the critical care unit of a medical center answers the phone and the person says, "There is a bomb in the hospital kitchen." Which action should the nurse take? 1. Notify the kitchen that there is a bomb. 2. Call the operator to trace the phone call. 3. Notify the hospital security department. 4. Call the local police department.

3. The chain of command in a hospital is to notify the security department, and they will institute the hospital procedure for the bomb threat.

The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's abdominal dressing for drainage. 3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

3. The client is 2 days postoperative and vital signs should be stable, so the UAP can take vital signs. The nurse must make sure the UAP knows when to immediately notify him/her of vital signs not within the guidelines the nurse provides to the UAP. 4. This action does not require judgment on the part of the UAP: it does not require assessing, teaching, or evaluating. This can be delegated to the UAP. 5. A client who is 2 days postoperative should be ambulating frequently. The UAP can perform this task.

The admitting nurse is subpoenaed to give testimony in a case in which the client fell from the bed and fractured the left hip. The nurse initiated fall precautions on admission but was not on duty when the client fell. Which issue should the nurse be prepared to testify about the incident? 1. What preceded the client's fall from the bed. 2. The extent of injuries the client sustained. 3. The client's mental status before the incident. 4. The facility's policy covering falls prevention.

4. The nurse initiated a policy that is designed to prevent falls from occurring. This is all the nurse can testify to.

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit. 2. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles. 3. The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain. 4. The client with Crohn's disease who has right lower abdominal pain and has diarrhea.

4. The client with Crohn's disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse. Pain could indicate a complication.

. The client in the operating room states, "I don't think I will have this surgery after all." Which intervention should the nurse implement first? 1. Have the surgeon speak with the client. 2. Ask the client to discuss the concerns. 3. Continue to prep the client for surgery. 4. Immediately stop the surgical procedure.

4. Stopping the surgical procedure is the first intervention for the nurse to implement.

At 0830, the day shift nurse is preparing to administer medications to the client. Which action should the nurse take first? 1.Check the client's armband against the medication administration record (MAR). 2. Assess the client's IV site for redness and patency. 3. Ask for the client's date of birth. 4. Determine the client's last K_ level.

4. The nurse should assess the client's last potassium (K+) level because hypokalemia (abnormally low K+ level) is the most common cause of dysrhythmias in clients receiving digoxin secondary to clients concurrently taking diuretics. Furosemide (Lasix) is a loop diuretic. The nurse should check for digoxin and K+ levels and apical pulse (AP) prior to administering digoxin.

The unconscious 4-year-old child with bruises covering the torso in varying stages of healing is brought to the emergency department by paramedics. The nurse notes small burn marks on the child's genitalia. Which actions should the nurse implement? Select all that apply. 1. Notify Child Protective Services. 2. Ask the parent how the child was injured. 3. Perform a thorough examination for more injuries. 4. Tell the parents that the police have been called. 5. Prepare the child for skull x-rays and a CT scan.

1, 3, and 5 are correct.

The nurse is preparing to administer the client's first intravenous antibiotic. Prioritize the nurse's actions from first (1) to last (5). 1. Check the healthcare provider's order in the chart. 2. Determine if the client has any known allergies. 3. Hang the secondary IV piggyback higher than the primary IV. 4. Set the intravenous pump at the correct rate. 5. Determine if the antibiotic is compatible with the primary IV.

1, 5, 2, 3, 4

The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

1. A secondary nursing intervention includes screening for early detection. The bone density evaluation will determine the density of the bone and is diagnostic for osteoporosis

The family member of a client in a long-term care facility is unhappy with the care being provided for the loved one. Which person would be most appropriate to investigate the complaint and report the findings during a client care conference? 1. The ombudsperson for the facility. 2. The social worker for the facility. 3. The family member who is unhappy. 4. The director of nurses

1. An ombudsman is a representative appointed to receive and investigate complaints made by individuals of abuses or capricious acts. All Medicare and Medicaid long-term care facilities must have an ombudsman to act as a neutral party in matters of dispute with the facility. This is the best person to investigate a complaint

The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering? 1. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery. 2. The anticoagulant enoxaparin (Lovenox) to a client who had a TKR. 3. The sliding scale insulin Humalog to a client who had a Whipple procedure. 4. The aminoglycoside vancomycin to a client allergic to the antibiotic penicillin.

1. Antiplatelet medication will increase the client's bleeding time and should be held 5 days prior to surgery; therefore, this medication should be questioned.

The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? 1. Evaluate the job performance of the staff. 2. Be the sole decision maker for the unit. 3. Take responsibility for the staff nurse's actions. 4. Attend the medical staff meetings.

1. One of the many jobs of a manager is to see that performance evaluations are completed on the staff.

The unlicensed assistive personnel (UAP) accidentally pulled the client's chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? 1. Securely tape petroleum gauze over the insertion site. 2. Instruct the UAP how to move a client with a chest tube. 3. Assess the client's respirations and lung sounds. 4. Obtain a chest tube and a chest tube insertion tray.

1. Taping petroleum gauze over the chest tube insertion site will prevent air from entering the pleural space. This is the first intervention.

A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement? 1. Tell the HCP that the jokes are inappropriate and offensive. 2. Report the behavior to the medical staff committee. 3. Discuss the problem with the chief nursing officer. 4. Call a Code Purple and have the nurses surround the HCP.

1. Telling jokes with sexual innuendos creates a "hostile work environment" and should be addressed with the HCP. This is a courtesy to the HCP to allow him to correct the behavior without being embarrassed.

The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? 1. Instruct her to assist the client with a shower. 2. Ask her to prepare the breakfast meal for the client. 3. Request her to take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

1. The HH aide's responsibility is to care for the client's personal needs, which includes assisting with a.m. care.

The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? 1. Administer PO medications to a client diagnosed with gastroenteritis. 2. Take the routine vital signs for all the clients on the pediatric unit. 3. Transcribe the HCP's orders into the computer. 4. Assess the urinary output of a client diagnosed with nephrotic syndrome

1. The LPN can administer routine medications.

The charge nurse overhears two unlicensed assistive personnel (UAPs) discussing a client in the hallway. Which action should the charge nurse implement first? 1. Remind the UAPs that clients should not be discussed in a public area. 2. Tell the unit manager that the UAPs might have been overheard. 3. Have the UAPs review policies on client confidentiality and HIPAA. 4. Find some nursing tasks the UAPs can be performing at this time.

1. The charge nurse should remind the UAPs not to discuss confidential information in a public place. This is the first action.

The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client? 1. Restrain the client's wrists, as needed. 2. Offer the client fluids every 2 hours. 3. Apply a hand mitt to the arm opposite the IV site for 12 hours. 4. Check circulation of the restrained limb every 2 hours.

1. The client cannot be restrained as needed. The nurse must have documentation for the need and an HCP's specific order that includes reason for restraint and time limited to no more than 24 hours. This HCP order should be clarified.

The resident in a long-term care facility tells the nurse, "I think my family just put me here to die because they think I am too much trouble." Which statement is the nurse's best response? 1. "Can you tell me more about how you feel since your family placed you here?" 2. "Your family did what they felt was best for your safety." 3. "Why would you think that about your family? They care for you." 4. "Tell me, how much trouble were you when you were at home?"

1. The client is expressing negative feelings about being placed in the nursing home. Asking about the client's feelings is a therapeutic response that encourages the client to discuss his or her feelings.

Which situation would prompt the healthcare team to utilize the client's advance directive when needing to make decisions for the client? 1. The client with a head injury who is exhibiting decerebrate posturing. 2. The client with a C-6 spinal cord injury (SCI) who is on a ventilator. 3. The client in chronic renal disease who is being placed on dialysis. 4. The client diagnosed with terminal cancer who is mentally retarded.

1. The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the advance directive. A client who is exhibiting decerebrate posturing is unconscious and unable to make decisions.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The client who had surgery for an inguinal hernia and who is being prepared for discharge. 2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. 3. The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. 4. The client who has end-stage renal disease and who has had an arteriovenous fistula created.

1. The most experienced nurse should be assigned to the client who requires teaching and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day.

The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first? 1. Pre-medicate the client with a narcotic analgesic. 2. Prepare the equipment and bandages at the bedside. 3. Remove the old dressing with non-sterile gloves. 4. Place a sterile glove on the dominant hand.

1. The nurse should first medicate the client since this procedure is very painful for the client.

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. 2. The client diagnosed with pneumonia who has an oral temperature of 100.2°F. 3. The client diagnosed with cystitis who complains of burning on urination. 4. The client diagnosed with pancreatitis who complains of pain that is an 8

1. The therapeutic PTT level should be 11 /2 to 2 times the control. Most controls average 36 seconds, so the therapeutic levels of heparin would place the control between 54 and 72. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first.

The nurse has received the shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom. 2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. 3. The client diagnosed with pancreatitis who wants the nasogastric tube removed. 4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

1. This client is exhibiting signs and symptoms of a potentially fatal complication of DVT—pulmonary embolism. The nurse should assess this client first.

The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? 1. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough. 2. The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds. 3. The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer. 4. The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis.

1. This client may be developing a complication of immobility, one of which is pneumonia. The nurse should assess this client first.

Which situation should the charge nurse in the critical care unit address first after receiving the shift report? 1. Talk to the family member who is irate over his loved one's nursing care. 2. Complete the 90-day probationary evaluation for a new ICU graduate intern. 3. Call the laboratory concerning the type and crossmatch for a client who needs blood. 4. Arrange for a client to be transferred to the telemetry step-down unit.

1. This situation should be addressed first because the charge nurse is responsible for family/client complaints. If the family contacts the administration, the charge nurse must be aware of the situation.

The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee? 1. Discuss the nurse's actions with the unit manager. 2. Confront the nurse about the behavior. 3. Do not allow the nurse to take breaks alone. 4. Prepare an occurrence report on the employee.

1. Usually, the charge nurse should attempt to settle a conflict at the lowest level possible, in this case, confronting the nurse. However, the charge nurse does not have the authority to require a drug screen, which is the intervention needed in this situation. The nurse should notify the unit manager

The nurse in the burn unit is preparing to perform a wound dressing change at the bedside. Which interventions should the nurse implement? Rank in order of priority. 1. Obtain the needed supplies for the procedure. 2. Explain the procedure to the client. 3. Remove the old dressing with non-sterile gloves. 4. Medicate the client with narcotic analgesics. 5. Assess the client's burned area.

2, 4, 1, 3, 5

The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit. 1. Extinguish. 2. Rescue. 3. Confine. 4. Alert.

2, 4, 3, 1

Which client should the nurse in the post-anesthesia care unit (PACU) assess first? 1. The client who received general anesthesia who is complaining of a sore throat. 2. The client who had right knee surgery and has a pulse oximeter reading of 90%. 3. The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse. 4. The client who had abdominal surgery and has green bile draining from the N/G

2. A pulse oximeter reading of less than 93% indicates an oxygenation problem; therefore, this client should be assessed first.

The client tells the nurse, "I am having surgery on my right knee." However, the operative permit is for surgery on the left knee. Which action should the nurse implement first? 1. Notify the operating room team. 2. Initiate the time-out procedure. 3. Clarify the correct extremity with the client. 4. Call the surgeon to discuss the discrepancy

2. According to the Joint Commission, the first intervention is to call a time-out, which stops the surgery until clarification is obtained.

The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? 1. Tell the unlicensed assistive personnel (UAP) to ambulate the client with the walker. 2. Request a referral to the physical therapy department. 3. Obtain a walker that is appropriate for the client's height. 4. Notify the social worker of the HCP's order for a walker.

2. According to the National Council of State Boards of Nursing (NCSBN), collaboration with interdisciplinary team members is part of the Management of Care. Physical therapy is responsible for management of the client's ability to move and transfer

The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first? 1. The 4-year-old child who fell and is complaining of left leg pain. 2. The 3-year-old child who is drooling and does not want to swallow. 3. The 8-year-old child who has complained of a headache for 2 days. 4. The 10-year-old child who is thirsty all the time and has lost weight.

2. Drooling and not wanting to swallow are the cardinal signs of epiglottitis, which is potentially life threatening. This child should be assessed first. The nurse should not attempt to visualize the throat area and should allow the HCP to do this in case an emergency tracheostomy is required.

A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement? 1. Request all family members to leave the hospital as soon as possible. 2. Instruct the staff to plug critical electrical equipment into the red outlets. 3. Have the unlicensed assistive personnel (UAP) place a portable flashlight on each bedside table. 4. Contact the maintenance department to determine how long the electricity will be out.

2. During an electrical failure, the red outlets in the hospital run on the backup generator, and all IV pumps and necessary equipment should be plugged into these outlets.

The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon? 1. The client who is 2 days postoperative for bowel resection and who refuses to turn, cough, and deep breathe. 2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away. 3. The client who is 2 hours postoperative for TKR and who has 400 mL in the cell-saver collection device. 4. The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign.

2. Feeling a "pop" after an abdominal hysterectomy may indicate possible wound dehiscence, which is a surgical emergency and requires the nurse to notify the surgeon via telephone.

Which legal intervention should the nurse implement on the initial visit when admitting a client to the home healthcare agency? 1. Discuss the professional boundary-crossing policy with the client. 2. Provide the client with a copy of the NAHC Bill of Rights. 3. Tell the client how many visits the client will have while on service. 4. Explain that the client must be homebound to be eligible for home healthcare.

2. Home healthcare agencies are required by law to address the concepts in the National Association for Home Care (NAHC) Bill of Rights with all home health clients on the initial visit. The agencies may also make additions to the NAHC's original Bill of Rights.

The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? 1. Place a Posey vest restraint on the client. 2. Move the client to a room near the station. 3. Ask the HCP for an antipsychotic medication. 4. Raise all four side rails on the client's bed.

2. Moving the client near the nursing station where the staff can closely observe the client is one of the first measures in most fall prevention policies.

The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first? 1. Discuss the infections with the chief nursing officer. 2. Contact the infection control nurse to discuss the problem. 3. Assume the employee health nurse is monitoring the situation. 4. Volunteer to be on an ad hoc committee to research the infection rate.

2. Possibly increasing infection rates among clients with PICCs falls within the infection control nurse's scope of practice, and the infection control nursing staff will have data from all units in the hospital.

The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments? 1. The RN will perform the shift assessments. 2. The LPN should administer all IVP medications. 3. The UAP will complete all a.m. care. 4. The RN will monitor laboratory values.

2. The LPN may be allowed administer some IVP medications in some facilities, but the word "all" makes this an inappropriate assignment. Many IVP medications are considered high risk, and only RNs should administer such IVP medications.

Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

2. The UAP can take specimens to the laboratory; these are not medications and they are not vital to the client.

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit? 1. Escort the client to the smoking area outside. 2. Obtain vital signs on a newly admitted client. 3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.

2. The UAP can take vital signs on a newly admitted client.

The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? 1. The UAP is not at risk for contracting an illness. 2. The UAP should wear a mask, gown, and gloves. 3. The UAP may skip performing postmortem care. 4. Ask whether the UAP is pregnant before she enters the client's room.

2. The UAP should wear appropriate personal protective equipment when providing any type of care.

The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? 1. Reinsert the nasogastric tube for the client who has pulled it out. 2. Complete the preoperative checklist for the client scheduled for surgery. 3. Instruct the client who is being discharged home about colostomy care. 4. Change the client's surgical dressing that has a 20 cm area of drainage

2. The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client's safety.

The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? 1. Ask the charge nurse to teach all the other UAPs. 2. Encourage the nurse to continue to work with the UAP. 3. Tell the charge nurse to discuss this in a private area. 4. Give the UAP a better explanation of the procedure.

2. The director of nurses should encourage responsible behavior on the part of all staff. The charge nurse is performing a part of the responsibility of the charge nurse and should be encouraged to work with the UAP.

The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? 1. Have another employee drive the clients home. 2. Notify the public health department immediately. 3. Send the clients to the emergency department. 4. Obtain stool specimens from the clients.

2. The employee health nurse should be aware that six clients with the same signs/ symptoms indicate a potential deliberate or accidental dispersal of toxic or infectious agents. The nurse must notify the public health department so that an investigation of the cause can be instituted and appropriate action to contain the cause can be taken.

. The hospital will be implementing a new medication administration record (MAR) for documenting medication administration. Which action should the clinical manager take first when implementing the new MAR? 1. Discuss the new MAR with each nurse individually. 2. Schedule meetings on all shifts to discuss the new MAR. 3. Require the nurse to read a handout explaining the new MAR. 4. Ask the nurses to watch a video explaining the new MAR.

2. The first intervention should be to arrange meetings to explain the new MAR and allow nurses to ask questions to clarify the new policy

The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers? 1. No information can be released to the mortuary service. 2. The nurse should tell the funeral home the client's diagnosis. 3. Ask the family for permission to talk with the mortician. 4. Refer the funeral home to the HCP for information.

2. The mortuary service is considered part of the healthcare team. In this case, the personnel in the funeral home should be made aware of the client's diagnosis.

The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

2. The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation.

The nurse in an assisted living facility notes that the male client has several new bruises on both of his arms and hands. Which intervention should the nurse implement first? 1. File an elder abuse report with the Department of Human Services. 2. Ask the client whether he has fallen and hurt himself during the night. 3. Check the medication administration record (MAR) to determine which medications the client is receiving. 4. Notify the client's family of the bruises so they are not surprised on their visit.

2. The nurse should ask the client whether there is a reason for the bruises that the nurse should be aware of. This is the first intervention and can be done while the nurse is currently with the client.

The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney. 2. Review the client's chart. 3. Purchase personal liability insurance. 4. Discuss the case with the supervisor.

2. The nurse should be familiar with the chart and the situation so that details can be remembered. This should be the nurse's first action.

The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? 1. Immediately give a 2-week notice and find a different job. 2. Discuss the situation with the manager who interviewed him. 3. Talk with the other employees about the staffing situation. 4. Tell the charge nurse the staffing is not what was explained to him.

2. The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such as illness, may be affecting staffing.

The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."

2. The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client.

The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

2. The shift manager should have objective data prior to confronting the UAP about the allegation of falsifying vital signs; therefore, the shift manager should take the client's vital signs and compare them with the UAP's results before taking any other action

The HCP is angry and yelling in the nurse's station because the client's laboratory data are not available. Which action should the charge nurse implement first? 1. Contact the laboratory for the client's results. 2. Ask the HCP to step into the nurse's office. 3. Tell the HCP to discuss the issue with the laboratory. 4. Report the HCP's behavior to the chief nursing officer.

2. This is the charge nurse's first action because it will diffuse the HCP's anger. Inappropriate behavior at the nurse's station should not occur in an area where visitors, clients, or staff will observe the behavior.

The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? 1. The nurse who has the most vacation time. 2. The nurse who requested to be off. 3. The nurse who has the least experience on the unit. 4. The nurse who has called in sick the previous 2 days.

2. This nurse wants to take time off. Therefore, it is the best option to let the nurse desiring to be off from work to take time off if all other situations are equal.

The critical care unit is having problems with staff members clocking in late and clocking out early from the shift. Which statement by the charge nurse indicates he has a democratic leadership style? 1. "You cannot clock out 1 minute before your shift is complete." 2. "As long as your work is done you can clock out any time you want." 3. "We are going to have a meeting to discuss the clocking in procedure." 4. "The clinical manager will take care of anyone who clocks out early."

3. A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open and communication flows both ways, and this includes having meetings to discuss concerns.

The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? 1. The client diagnosed with flail chest who has just come from the operating room with a right-sided chest tube. 2. The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy. 3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact. 4. The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism

3. Although the client is only 1 day postoperative for a total hip replacement, it is an elective procedure, which indicates that the client was stable prior to the surgery. The incision is also dry and intact. Of the four clients, this client is the most stable and should be transferred to the surgical unit.

A major disaster has been called, and the charge nurse on a medical unit must recommend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? 1. The client diagnosed with chronic angina pectoris who has been on new medication for 2 days. 2. The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days. 3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection. 4. The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH, 7.34; PCO2, 55; HCO3, 28; PaO2, 89.

3. Because resistant infections are very difficult to treat, this client should remain in the hospital for the required IVPB medication.

The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? 1. Tell the HH aide to allow the client to stay in bed until the pain goes away. 2. Instruct the HH aide to get the client up to a chair and give her a bath. 3. Explain to the HH aide the client should get up and take a warm shower. 4. Arrange an appointment for the client to visit her healthcare provider

3. Movement and warm or hot water will help decrease the pain; the worst thing the client can do is not to move. The HH aide should encourage the client to get up and take a warm shower or bath.

The home health (HH) nurse along with an HH aide is caring for a client who is 3 weeks postoperative for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide? 1. Instruct the HH aide to palpate the right pedal pulse. 2. Ask the HH aide to change the right hip dressing. 3. Tell the HH aide to elevate the right leg on two pillows. 4. Request the HH aide to mop the client's bedroom floor.

3. The HH aide can place the right leg on two pillows. This task does not require assessment, teaching, or evaluating, and the client is stable.

The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? 1. Administer a pain medication 30 minutes before therapy. 2. Give the client a washcloth to wash his or her face before walking. 3. Check to make sure the client has been offered the use of the bathroom. 4. Find a walker that is the correct height for the client to use.

3. The client should be ready to work on therapy when the physical therapist arrives. The UAP should make sure the client has used the bathroom or has not been incontinent before the therapist arrives, thus making the most efficient use of the therapist's time.

The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.

3. The client will need to be pre-medicated for a wound debridement; therefore, this task cannot be delegated to the UAP.

The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first? 1. Increase the client's intravenous rate. 2. Assess the client's vital signs. 3. Apply a tourniquet above the amputation. 4. Notify the client's healthcare provider.

3. The nurse should keep a large tourniquet at the client's bedside and should apply it when suspecting arterial bleeding; this is the nurse's first intervention.

The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client? 1. To a home healthcare agency. 2. To a senior citizen center. 3. To a rehabilitation facility. 4. To an outpatient physical therapist.

3. The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client's recovery.

The newly admitted client in a long-term care facility stays in the room and refuses to participate in client activities. Which statement is a priority for the nurse to discuss with the client? 1. "You have to get out of this room or you will never make friends here at the home." 2. "It is not so bad living here; you are lucky that we care about what happens to you." 3. "You seem sad; would you like to talk about how you are feeling about being here?" 4. "The activities director can arrange for someone to come and visit you in your room."

3. This client is exhibiting symptoms of depression. Therapeutic conversation is implemented to help the client vent feelings. This statement acknowledges the client's feeling and offers help.

The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, "I don't want to go to the nursing home but my son says I have to." Which response would be most appropriate by the nurse? 1. "Let me call a meeting of the healthcare team and your son." 2. "Has the social worker talked to you about this already?" 3. "Why are you so upset about going to the nursing home?" 4. "I can see you are upset. Would you like to talk about it?"

4. According to the NCLEX-RN® test plan, advocacy is part of Management of Care under Safe and Effective Care Environment client needs. Therapeutic communication involves being an advocate in this situation, because sometimes the nurse cannot prevent a perceived "bad" situation from occurring.

Which client would most benefit from acupuncture, a traditional Chinese medicine considered complementary alternative medicine? 1. The client who is diagnosed with deep vein thrombosis. 2. The client who is diagnosed with Alzheimer's disease. 3. The client diagnosed with reactive airway disease. 4. The client diagnosed with osteoarthritis.

4. Acupuncture, the most common com - plementary therapy recommended by healthcare providers, would benefit a client with osteoarthritis.

The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement? 1. Discuss the situation with the client's family. 2. Refer the client to the HH occupational therapist. 3. Request the HH aide to cook all the client's meals. 4. Contact the community's Meals on Wheels.

4. Meals on Wheels delivers a hot, nutritionally balanced meal once a day on weekdays, usually at noon for older people who do not have assistance in the home for food preparation. This intervention would be most helpful to the client.

The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheelchair. Which priority action should the HH nurse tell the HH aide? 1. Explain how to perform isometric exercises. 2. Instruct her to go to the local emergency room. 3. Tell her to complete an occurrence report. 4. Recommend that she apply an ice pack to the back.

4. The HH aide is in pain, and applying ice to the back will help decrease pain and inflammation. The HH nurse should be concerned about a coworker's pain. Remember: Ice for acute pain and heat for chronic pain.

The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement? 1. Bathe the client who is incontinent of urine. 2. Document the amount of food the client eats. 3. Conduct the afternoon bingo game in the lobby. 4. Perform routine dressing changes on assigned clients.

4. The LPN's scope of practice allows routine sterile procedures on the client who is stable, such as clients in a surgical rehabilitation facility.

The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing? 1. The client diagnosed with AIDS who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled. 3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

4. The client diagnosed with diabetic neuropathy would be expected to have pain; therefore, this client could be assigned to a nurse new to home health nursing. The client is not exhibiting a complication or an unexpected sign/symptom.

The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first? 1. The client who is 4 hours postoperative for abdominal surgery who is complaining of abdominal pain and has hypoactive bowel sounds. 2. The client who is 1 day postoperative for total hip replacement (THR) who has voided 550 mL of clear amber urine in the last 8 hours. 3. The client who is 8 hours postoperative for open cholecystectomy who has a T-tube draining green bile. 4. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot

4. The client is exhibiting signs of compromised circulation; therefore, the nurse should assess this client first. The nurse should assess for the 6 Ps: pain, pulse, paresthesia, paralysis, pallor, and polar (cold).

The male client in a long-term care facility complains that the staff does not listen to his complaints unless a family member also complains. Which action should the director of nurses implement? 1. Call a staff meeting and tell the staff to listen to the resident when he talks to them. 2. Determine who neglected to listen to the resident and place the staff member on leave. 3. Ignore the situation because a resident in long-term care cannot determine his needs. 4. Talk with the resident about his concerns and then initiate a plan of action.

4. The director of nurses should discuss the resident's complaints with the resident and then determine a plan of action to remedy the situation.

The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

4. The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks.

The head nurse is completing the yearly performance evaluation on a nurse. Which data regarding the nurse's performance should be included in the evaluation? 1. The number of times the nurse has been tardy. 2. The attitude of the nurse at the client's bedside. 3. The thank you notes the nurse received from clients. 4. The chart audits of the clients for whom the nurse cared.

4. The nurse's ability to document client care directly correlates with the nurse's performance; therefore, these data should be included in the yearly evaluation.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction (MI) who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

4. The therapeutic range for Dilantin is 10 to 20 mg/dL. This client's higher level warrants intervention because the serum level is above the therapeutic range.