Leadership Midterm

A 50-car pileup occurs on a major freeway in California's Central Valley as a result of heavy fog. There are major injuries, and victims are expected to be transported to local emergency departments. Which type of disaster is this classified as: 1. Mass casualty event 2. Conventional disaster 3. Biological disaster 4. Radiological disaster

1

In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1

Hospital leadership should consider which of the following ethical dilemmas prior to experiencing an actual disaster? (Select all that apply.) 1. Which clinical leader will make the decision about distribution of scarce resources 2. Criteria to determine which patients receive aggressive treatment and which will receive palliative care 3. Which nursing staff will be the first to report to the hospital in the event of a disaster 4. How prophylactic pharmaceuticals will be distributed to protect staff and their families 5. Who will be primarily responsible for external communication

1, 2 , 4

Which cancer patients could be placed together as roommates? Select all that apply. 1. A patient who has a very low neutrophil count 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who had a laminectomy for spinal cord compression 5. A patient who is undergoing brachytherapy for prostate cancer 6. A patient with terminal cancer who is receiving end-of-life care

2, 4

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

2, 5, 6

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown and the client has sustained a severe head injury with multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure 2. Ask the EMS team to sign the informed consent 3. Transport the victim to the operating room for surgery 4. Call the police to identify the client and locate the family

3

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

3

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? A)A victim experiencing dyspnea B)A victim experiencing confusion C)A victim experiencing tachycardia D)A victim experiencing intense pain

A

1.) The RN is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the Unlicensed Assistive Personnel (UAP) to provide quality care to the client? (SATA). a. Record vital signs b. Assisting the client while bathing c. Administering oral medication d. Preparing the care plan for the client e. Administering intravenous antibiotics

AB

1.) Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions are most appropriate? (SATA) a. The nurse needs to know the Good Samaritan Act for the state. b. The nurse is not held liable unless there is a gross negligence. c. After assessing the situation, the nurse can leave to obtain help. d. The nurse can expect compensation for helping. e. The nurse offers to help but cannot insist on helping.

ABE

1.) As the registered nurse, which tasks below should you NOT delegate to the LPN? a. Performing an assessment on a new admission. b. Collecting a urine sample from an indwelling Foley catheter. c. Developing a plan of care for a patient who is admitted with Guillain- Barre Syndrome. d. Educating a patient about how to monitor for side effects associated with Warfarin. e. Auscultating lung and bowel sounds. f. Starting a blood transfusion. g. Administering IV Morphine 2 mg for pain. h. Providing wound care to a stage 3 pressure injury.

ACDFG

1.) A nurse triages a client arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA) a. A 35 - year - old female with severe chest pain; red tag b. A 42 - year - old male with full - thickness body burns; green tag c. A 55 - year - old female with a scalp laceration; black tag d. A 60 - year - old male with an open fracture with distal pulses; yellow tag e. An 88 - year - old male with shortness of breath and chest bruising; green tag

AD

1.) An RN is caring for an 80 - year - old male patient who has been admitted to the hospital. The RN delegates several tasks to the UAP. In order to evaluate the understanding of the UAP, the RN asks the UAP to describe which tasks have been delegated. Which responses given by the UAP indicate effective understanding of the tasks? (SATA). a. I must assist the patient with oral care. b. I must assess the patient's health status. c. I must administer intravenous drug pain medication. d. I must record the blood pressure of the patient at regular intervals.

AD

1.) Which are examples of internal disasters that must be accounted for when formulating a disaster response plan? (SATA). a. Fire b. Hurricane c. Earthquake d. Power Outage e. Act of Terrorism

AD

1.) Which patients below are best assigned to the LPN? (SATA) a. A 30 - year - old male patient with active GI bleeding that requires multiple blood transfusions. b. A 78 - year - old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. c. A 29 - year - old male patient who is post op day 6 from a colostomy placement that is on a clear liquid diet. d. A 55 - year - old male patient who reports chest pain and has ST segment elevation on his EKG.

BC

1.) The nurse is called from the hospital to assist the emergency medical technicians in a disaster response. The nurse classifies some victims into the black - tagged category based on what assessment findings? a. Leg fracture b. Massive head trauma c. Abrasions and contusions d. Full thickness body burns e. High cervical spinal cord injury

BDE

1.) You're making the patient assignments for the next shift. On your unit there are three LPNs, two RNs, and two nursing assistants. Which patients will you assign to the LPNs? (SATA). a. A 68-year-old male patient who is expected to be discharged home with IV antibiotic therapy. b. A 25-year-old female patient newly admitted with diabetic ketoacidosis. c. A 75-year-old male patient with dementia who has an ileostomy and scheduled tube feedings. d. A 65-year-old female patient who has an order to remove the Foley catheter.

CD

1.) While caring for the postoperative client following a total laryngectomy with radical neck dissection, the nurse observes that the client is restless and has a respiratory rate of 28 BPM. Which action is the nurse's priority? a. Suction the client's laryngectomy tube. b. Apply oxygen by mask at 4 liters per minute. c. Elevate the head of the client's bed to 45 degrees. d. Assess the client's oxygen saturation level.

D

1.) The nurse receives change in shift report on four assigned clients. Prioritize the order that the nurse should assess the clients. a. The 47 - year - old client two days postoperative who has pain rated at a 2 on a 0 to 10 pain scale. b. The 82 - year - old client who was unable to void and has a bladder scan showing 300 mL of urine. c. The 76 - year - old client newly admitted with serum blood urea nitrogen of 52 mg/dL d. The 57 - year - old client with hypertension who has severe midsternal pain.

DCBA

1). A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? A. Immobilize the affected limb with a splint and ask him not to move. B. Make a thorough assessment of the circumstances surrounding the accident. C. Put him in semi-Fowler's position for comfort. D. Check the pedal pulse and blanching sign in both legs.

a

1.) A client was brough to the emergency department after suffering a closed head injury and lacerations around the face due to a hit - run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after a few hours, should be reported to the physician immediately? a. Drainage of a clear fluid from the client's nose b. Withdrawal of the client in response to painful stimuli c. Bruises and minimal edema of the eyelids d. Bleeding around the lacerations

a

1.) A nurse is assigned to provide care to a client in labor and will care for the client throughout labour and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labour is which of the following? a. Assessing the uterine fundus and lochia. b. Checking the mother's temperature. c. Encouraging food and fluid intake. d. Providing privacy for the parents and their newborn infant.

a

1.) A triage nurse encountered a client who complained of mid - sternal chest pain, dizziness, and diaphoresis. Which of the following nursing actions should take priority? a. Administer oxygen therapy via nasal cannula b. Notify the physician c. Complete history taking d. Put the client on ECG monitoring

a

1.) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action net? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall.

a

1.) The nurse is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? a. Removing the stinger by scraping it b. Applying a cold compress c. Taking an oral antihistamine d. Calling 911

a

1.) The nurse is making telemetry unit assignments. Which patient assignment should be given to the licensed practical nurse? a. Client 2 days after having an aortic valve surgery who needs a urinary catheter inserted due to inability to void. b. Client discharged after DVT who needs teaching on Lovenox administration. c. Client recently discharged to unit with suspected myocardial infarction. d. Client on nitroglycerin infusion drip with titration prescription from MD.

a

1.) The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? a. Observe how well the patient performs pursed - lip breathing b. Plan a nursing care regimen that gradually increases activity intolerance. c. Assist the patient with basic activites of daily living. d. Consult with the physical therapy department about reconditioning exercises.

a

1.) When the nurse described the client as "that nasty old man in 354," the nurse is exhibiting which ethical dilemma? a. Gender bias and ageism b. HIPAA violation c. Beneficence d. Code of ethics violation

a

1.) Which statement represents a situation in which delegation is ineffective or inappropriate? a. The RN asks the LPN to assist with admissions by assessing the clients as they get to their rooms. b. The RN delegates administration of oral medications for a group of clients to the LPN. c. The LPN directs the unlicensed assistant to report vital sign changes on a post - operative client to the RN. d. The nurse manager asks the RN to act as a chairperson for today's unit council meeting since the charge nurse went home sick.

a

1.) You are caring or a patient with esophageal cancer. Which task could be delegated to a UAP? a. Assisting the patient with oral hygiene. b. Observing the patient's response to feedings. c. Facilitating expression of grief or anxiety. d. Initiating daily weights.

a

1.) A hospitalized client with type 1 diabetes mellitus tells the nurse that they feel like they are having a hypoglycemia reaction. The nurse should complete which action first? a. Prepare to administer 50 % dextrose intravenously. b. Obtain a blood glucose reading. c. Give the patient 4 oz of orange juice d. Prepare to administer subcutaneous glucagon hydrochloride.

b

1.) A nurse who works the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid. Which is the most appropriate action by the nurse? a. Call the police b. Call the nursing supervisor c. Call security d. Lock the coworker in the medication room until help is obtained

b

1.) Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: a. Consult a professional ethicist to ensure that the steps of the process occur in full. b. Gather all relevant information regarding the clinical, social, and spiritual, aspects of the dilemma. c. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion. d. Ensure that the attending physician has written an order for an ethics consultation.

b

1.) The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? a. Administering IV fluids as prescribed by the physician. b. Providing straws and offering fluids between meals c. Developing a plan for added fluid intake over 24 hours. d. Teaching a family member to assist the client with fluid intake.

b

1.) The high - pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take next? a. Reassure the patient that the ventilator will do the work of breathing for him. b. Manually ventilate the patient while assessing possible reasons for the high - pressure alarm. c. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning. d. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

b

1.) The nurse puts a restraint jacket on a patient without the patient's permission and without a physician's order. The nurse could be found guilty of... a. Assault b. Battery c. Invasion of Privacy d. An unintentional tort

b

1.) The nurse receives report on the medical / surgical unit. Which client should the nurse see first? a. A client with an IV of NS 125 / hr complaining of slight swelling at the insertion site. b. Client 3 days post - op total knee replacement complaining of right calf pain with movement. c. Client with a respiratory rate of 24 and an O2 sat of 94% on room air. d. A client 12 hours after hysterectomy reporting nausea.

b

1.) When assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN under the supervision of the RN? a. A patient with severe anemia secondary to GI bleeding. b. A patient who needs enemas and antibiotics to control GI bacteria. c. A patient who needs preoperative teaching for bowel resection surgery. d. A patient who needs central line insertion for chemotherapy.

b

1.) Which of the following tasks is appropriate for the nurse to delegate to an experienced UAP? a. Obtain a 24- hour diet recall from a client recently admitted with anorexia nervosa. b. Obtain a clean - catch urine specimen from a client suspected of having a urinary tract infection c. Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection d. Observe a client newly diagnosed with diabetes mellitus practice injection techniques with an orange.

b

1.) You are the supervising nurse in an Emergency Department (ED) following mass casualty. Which of the following patients is improperly tagged by your staff? a. Black ~ A 32 - year - old female patient with extensive head injuries, a thready pulse and agonal breathing. b. Yellow ~ A 57 - year - old male patient limping with several minor lacerations on extremities. c. Red ~ An 80 - year - old female patient with a laceration on the head, altered mental status and respirations of 45 breaths per minute. d. Yellow ~ A 47 - year - old male patient complaining of 7/10 abdominal pain with notable bruising on the abdomen.

b

Which interventions are in the scope of a licensed practical nurse (LPN)? Select all that apply. A)Client teaching B)Ambulating the client C)Interpreting lab data D)Assisting the client with bathing E)Administering intramuscular medications

bde

1.) A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated, and the wounded are brought to the hospital. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You're helping triage the survivors. You would place what colour tag on this survivor? a. Red b. Yellow c. Green d. Black

c

1.) A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury, multiple fractures, and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure. b. Ask the EMS team to sign the informed consent. c. Transport the victim to the operating room for surgery. d. Call the police to identify the client and locate the family.

c

1.) A client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion. b. Discuss the case with coworkers. c. Notify the primary healthcare provider of the client's refusal of blood products. d. Explain to the client that they will die if they refuse the blood transfusion.

c

1.) A primary care provider's orders indicated that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, which statement "best" illustrates the nurse fulfilling the client advocate role? a. "The doctor has asked that you sign the consent form." b. "Do you have any questions about the procedure?" c. "What were you told about the procedure you are going to have?" d. "Remember that you can change your mind and cancel the procedure."

c

1.) Community stakeholders (local government, fire and rescue workers, hospitals) have been focused on gathering information from a variety of resources, developing collaborative response plans, and preparing for a probable disaster. As a nurse manager and leader, what steps are essential first? a. Engaging acute care facilities to be prepared and have a plan in place only for external disaster. b. The Health Insurance Portability and Accountability Act (HIPAA) and the Joint Commission (TJC) require all health care facilities to have detailed all - hazard preparedness plans and to conduct drills internally. c. Establishing all - hazards preparedness plan to create an all - hazards preparedness task force (AHPTF) that includes knowledge of the national response plan and state and local disaster response plans. d. Designing an all - hazards preparedness plan that includes only those in the internal organization.

c

1.) For a patient who is experiencing the side effects of radiation therapy, which task would be most appropriate to delegate to the UAP? a. Helping the patient to identify the patterns of fatigue. b. Recommending participation in a walking program. c. Reporting the amount and type of food consumed from the tray. d. Checking the skin for redness and irritation after the treatment.

c

1.) Nursing staff members are sitting in the lounge of taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks the unit secretary has acquired AIDS. She proceeds to tell the staff that the secretary probably contracted the disease from her husband who is supposedly a drug addict. The RN should inform the UAP that making this accusation has violated which legal tort? a. Libel b. Assault c. Slander d. Negligence

c

1.) People are knowledgeable about natural disasters within their local regions; however, many have not had to consider the devastation that can be caused by terrorism such as radiological exposures, nuclear blasts, conventional bombings, or agricultural contamination. Identify the correct statement. a. A chemical disaster is an incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children. b. A biological disaster is a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. c. A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology. d. A radiological / nuclear disaster is a foreseen and often sudden event with radioactive materials that causes great damage, destruction, and human suffering.

c

1.) The RN is planning assignments for the day. What is the most appropriate assignment that the RN can delegate to the UAP? a. A client requiring colostomy irrigation. b. A client requiring continuous tube feelings initiated. c. A client requiring a urine specimen collection. d. A client with difficulty swallowing both foods and liquids.

c

1.) The charge nurse handed out daily assignments to the nurse, which patient should be seen first? a. A patient whop recently had abdominal surgery complaining of right flank pain. b. A patient whose blood pressure is 90/70. c. A patient who had circumoral burns who is not complaining of shortness of breath. d. A patient who is on antihypertensives who is complaining of dizziness.

c

1.) The emergency medical service had transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and an impalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? a. Assisting with the intubation b. Placing the defibrillator pads c. Doing chest compressions d. Initiating bag valve mask ventilation

c

1.) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates, and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the occurrence. d. Call the laboratory and ask for the name of the individual who sent the photograph.

c

1.) The nurse has just received report on four patients. Which patient should the nurse assess first? a. A postoperative cholecystectomy patient who is complaining of pain but received an IM injection of morphine 5 minutes ago. b. A postoperative appendectomy patient who will be discharged in the next few hours. c. A patient with asthma who had difficulty breathing during the prior shift. d. An elderly patient with diabetes who is on the bedpan.

c

1.) The primary care provider wrote a do - not - resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? a. The client may no longer make decisions regarding his or her own health care. b. The client and family know that the client will most likely die within the next 48 hours. c. The nurses will continue to implement all treatments focused on comfort and symptom management. d. A DNR order from a previous admission is valid for the current admission.

c

1.) When a client is confused, let alone with the side rails down, and the bed is in a high position, the client falls and breaks a hip. What law has been broken? a. Assault b. Battery c. Negligence d. Civil Tort

c

1.) You're working as a triage nurse during a disaster situation. Based on the triage colour code tags placed on each of the wounded, which tag colour represents the wounded who have the highest priority of being treated first? a. Green b. Yellow c. Red d. Black

c

1.) Your patient with peptic ulcer disease has the following vital signs: BP 88/42, apical pulse 132, RR 28. You determine the nursing diagnosis for your patient as "altered tissue perfusion related to decreased circulatory volume." Which intervention should you implement first? a. Notify the laboratory to draw a type and crossmatch. b. Assess the patient's abdomen for tenderness. c. Insert an 18 - gauge catheter and infuse lactated Ringer's. d. Check the patient's pulse oximeter reading

c

1.) A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a. Providing range of motion exercises to the wrists. b. Removing the restraints periodically per agency guidelines. c. Applying lotion to the skin under the restraints. d. Assessing colour, sensation, and pulses distal to the restraint.

d

1.) A nurse receives report and starts making her plan for the day. Which patient should the nurse see first? a. 90 - year - old patient with resolving aspiration pneumonia complaining of SOB. b. 60 - year - old bilateral AKA patient complaining of pain in the legs. c. 35 - year - old 2 days post - op from colostomy with no stool excretion. d. 44 - year - old patient on a PCA pump who has reached lock out now showing respiration of 5 breaths per minute.

d

1.) A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is understaffed and needs an additional nurse to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action? a. Refuse to float to the ICU b. Call the hospital lawyer c. Call the nursing supervisor d. Report to the ICU and identify the tasks that can be safely performed

d

1.) After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? a. A 60 - year - old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. b. A 55 - year - old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. c. A 70 - year - old with pneumonia who needs to be started on IV antibiotics. d. A 50 - year - old with asthma who complains of shortness of breath after using a bronchodilator.

d

1.) An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff ta discharge clients from the medical - surgical units in order to make room for critically injured victims. b. Call additional medical - surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the ass casualty scene about how many victims may be handled by the ED. d. Direct medical - surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

d

1.) An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymosis areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? a. "Oh really? I will discuss this situation with your son." b. "Let's talk about the ways you can manage your time to prevent this from happening." c. "Do you have any friends who can help you out until you resolve these important issues with your son?" d. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

d

1.) People are knowledgeable about natural disasters within their local regions; however, many have not had to consider the devastation that can be caused by terrorism such as radiological exposures, nuclear blasts conventional bombings, or agricultural contamination. Identify the correct statement. a. A chemical disaster is an incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults or children. b. A biological disaster is a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. c. A radiological / nuclear disaster is a foreseen and often sudden event with radioactive materials that causes great damage, destruction, and human suffering. d. A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology.

d

1.) The nurse has received the patient assignment for the day. Which patient should the nurse care for first? a. The patient receiving chemotherapy who is on day 3 of a 5 - day regimen and has questions about nutrition. b. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area. c. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site. d. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination.

d

1.) The nurse is caring for a 56 - year - old female who started chemotherapy treatments 3 days ago. Which side effect warrants immediate intervention? a. Nausea and vomiting b. Loss of appetite c. Fatigue d. Paresthesia

d

1.) The resources for nurse executives, nurse leaders, or other nurse representatives would include some of the following references, but where should the managers begin to access knowledge about planning for disasters? a. Agency for Healthcare Research and Quality (AHRQ) b. American Hospital Association (AHA) c. Centers for Disease Control and Prevention (CDC) d. Federal Emergency Management Association (FEMA)

d

1.) You are providing nursing care for a 24 - year - old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? a. Teaching the patient how to secure a clean - catch urine sample. b. Assessing the patient's urine for colour, odour, and sediment. c. Reviewing the nursing care plan and add nursing interventions. d. Providing the patient with a clean - catch urine sample container.

d

A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: A.Comfort level B.Activity tolerance C.Level of consciousness D.Hydration and nutrition status

d

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider? 1. Stools have been black in color. 2. Bruising is present at the right groin. 3. Home blood pressure today was 104/52 mm Hg. 4. Home radial pulse rate has been 55 to 60 beats/min.

1

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weights

1

Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1, 3, 5, 6

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

1, 3, 5, 6

In a disaster, it is most important that the: 1. clients are sent home quickly. 2. medications and supplies are secure. 3. nurses and their families feel safe. 4. security department increases its workforce.

3

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

2

What are the two agencies that require all health care facilities to have detailed all-hazard preparedness plans? (Select two that are correct) 1. Patient Protection and Affordable Care Act 2. Health Insurance Portability and Accountability Act (HIPAA) 3. The Joint Commission 4. National Response Plan

2, 3

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

2, 3, 6

A primary care provider's orders indicated that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, which statement "best" illustrates the nurse fulfilling the client advocate role? 1. "The doctor has asked that you sign the consent form." 2. "Do you have any questions about the procedure?" 3. "What were you told about the procedure you are going to have?" 4. "Remember that you can change your mind and cancel the procedure."

3

For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen

4

At 9:00 PM, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine for gastroesophageal reflux disease. 3. The client has ST-segment elevations on the electrocardiogram (ECG). 4. The client reports having continuous chest pain since 8:00 AM.

4

What legal complications might a nurse face for using restraint without legal warrant on a client 1. The nurse may be charged with libel. 2. The nurse may be charged with negligence. 3. The nurse may be charged with malpractice. 4. The nurse may be charged with false imprisonment

4

Which client should the postpartum nurse assess first after receiving the a.m. shift report? A.The client who is complaining of perineal pain when urinating. B.The client who saturated multiple peri-pads during the night. C.The client who is refusing to have the newborn in the room. D.The client who is crying because the baby will not nurse.

b

Place the following clients in the order that the nurse should see them: a.) A client admitted for an acute asthma attack with respirations of 24 and a pulse ox reading of 91% b.) A patient who broke their radius in a motor vehicle accident complaining of 7/10 pain. c.) A Patient with a GI bleed that was on the call bell asking why they are not allowed to have cherry jell-owith their dinner d.) A client admitted for pneumonia who during shift report is now experiencing newly onset stridor

DABC

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? A.Vital signs B.Skin color C.Urine output D.Latest hematocrit level

a

). You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which patient should the nurse see first? A. Orange-colored urine in a patient who is taking Pyridiumand is post-op day 3 from a TURP. B. No stool excretion in a patient who is post-op day 2 from a colostomy. C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy. D. Pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy.

d

The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication.

1

Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider? 1. Temperature of 102.1°F (38.9°C) 2. Loud systolic murmur over sternum 3. Blood pressure of 110/88 mm Hg 4. Weak radial and pedal pulses to palpation

1

Which of the following questions should be considered in the hospital analysis survey of clinical operations readiness in the event of a disaster? (Select all that apply). 1. Does the facility have procedures in place to maximize staff safety in a disaster? 2. Does the facility have procedures in place for use of PPE? 3. Can the facility track patients until discharge or death while maintaining confidentiality? 4. Does the facility have a lockdown plan in case of emergency? 5. Does the facility have a mechanism of tracking costs associated with the event?

1, 2, 3

Nursing leadership competencies in disaster planning and crisis management encompass which of the following domains? (Select all that apply.) 1. Assessment of the disaster scene 2. Technical skills 3. Budget and resource allocation 4. Risk communication Critical thinking

1, 2, 4

The hospital plays an important role in the community in the case of a disaster. What are some of the expected roles of the hospital?(Select all that apply.) 1. Stockpiling emergency equipment 2. Purchasing personal protective equipment (PPE) 3. Providing additional security for the community 4. Educating staff on all-hazards preparedness 5. Providing emergency shelter to community members

1, 2, 4

In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1, 2, 4, 6

A disaster is a sudden event that can cause great destruction and human suffering and often requires external assistance. Which of the following statements are accurate depictions of various types of disasters or disaster-related definitions? (Select all that apply.) 1. A cyber disaster is a catastrophic event that results from the use of information technology systems. 2. A catastrophic event caused by the use of weapons is a radiological disaster. 3. A biological disaster occurs when there is a deliberate or unintentional release of biological materials that may affect the health of those exposed. 4. A chemical disaster occurs when there is deliberate or unintentional release of biological materials that may adversely affect the health of those exposed. 5. A hazard vulnerability analysis is an exercise that identifies an organization's potential emergencies.

1, 3, 5

All-hazards disaster is best defined as: 1. all types of natural and human terrorist events. 2. an event involving floods, tornadoes, hurricanes, and earthquakes. 3. an unforeseen and often unplanned event causing great damage. 4. any type of biological, chemical, radiological, or nuclear event.

1.

A health care system's ability to rapidly expand beyond normal capacity to meet an increased demand for qualified personnel, beds, and medical care services in the event of a large-scale emergency or disaster is known as: 1. acuity. 2. surge capacity 3. mass casualty 4. natural disaster

2

A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action? 1. Administer the medication 2. Notify the prescriber 3. Call the pharmacist 4. Refuse to administer the medication

2

A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to assign to an LPN/LVN? 1. Develop a "quit plan" 2. Explain how to apply a nicotine patch 3. Discuss strategies to avoid relapse 4. Suggest ways to deal with urges for tobacco

2

The nursing leadership role once the all-hazards preparedness plan is completed is to: 1. confirm that resources are allocated appropriately. 2. ensure that every facility department understands their role is a disaster situation. 3. establish goals for all-hazards preparedness. 4. provide rewards for the committee's accomplishments

2

When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

2

Testing the all-hazards preparedness plan requires drilling to identify and work through problems. Which of the following are examples of internal drills that can be used to test specific departments and/or hospital responses? (Select all that apply.) 1. Surge capacity drills 2. Lockdown of hospital entrances 3. Prioritization of police response to biological events 4. Simulating decontamination processes 5. Setting up the command center

2, 4, 5

The charge nurse discovers that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should the charge nurse take first? 1. Insist that they switch back to the original patient assignments and talk to each of them at the end of the shift. 2. Allow them this flexibility; as long as the patients are well cared for, it doesn't matter if the assignments are changed. 3. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues. 4. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings.

3

For care of a patient who has oral cancer, which task would be appropriate to assign to an LPN/LVN? 1. Assisting the patient to perform oral hygiene 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes

3

Based on this information in a client's medical record, which topic is the highest priority for the nurse to include in the initial teaching plan for a 26-year-old client who has blood pressures ranging from 150/84 to 162/90 mm Hg? Health History Physical Exam Social and Diet History • Denies any chronic health problems • Takes no medications Currently - Height: 5 feet, 6 inches - Weight: 115 lbs - BMI: 18.6 - Works as an accountant - 1 glass of wine once or twice weekly - Eats "fast food" frequently 1. Symptoms of acute stroke and myocardial infarction 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 0 to 10)

4

When working with the community, recognizable nomenclatureis important for: 1. response 2. education 3. reporting 4. communication

4

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A)Open doors to client rooms. B)Move beds away from windows C)Close window shades and curtains D)Place blankets over clients who are confined to bed. E)Relocate ambulatory clients from the hallways back into their rooms.

BCD

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? A.Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void B.Client being discharged after DVT who needs teaching on how to self administer enoxaparin injections C.Client who has just been admitted to the telemetry unit from the emergency department with a rule-out MI D.Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

A

On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated? Select all that apply. A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature, oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulation.

A, B

The nurse has dealt with an emergent situation and is attempting to catch up on scheduled tasks. The nurse plans to delegate some tasks to an unlicensed assistive personnel (UAP). Which of the following tasks are within the UAP's scope of practice and appropriate for the nurse to delegate? (Select all that apply.) A.Obtain vital signs and document appropriately in the client's medical record. B.Feed the client and assess the risk for aspiration. C.Assist the client with bathing and grooming. D.Perform indwelling urinary catheter care and appropriately document the client's I&O. E.Perform a sterile dressing change on a CVC. F.Ensure the client takes all medication left at the bedside by the nurse.

ACD

Chief nursing officers (CNOs) are accountable for establishing systems to assess, monitor, verify, and communicate ongoing competence requirements related to delegation, for both RNs and delegates. Which statements are correct? Select All That Apply. A.A key element in delegation is to assess the competency level of the staff. B.When an RN delegates a task, he or she is responsible for supervision, but is not accountable for the outcome. C.A state's nurse practice act consists of rules that govern how RNs delegate to competent staff. D.The National Council of State Boards of Nursing is opposed to delegation to unlicensed assistive personnel (UAP). E.Any traveling nurse unaware of the organizational systems in place to establish competency requirements for the unlicensed assistive persons.

ACE

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the bestunderstanding of the laissez-faire leadership style? A: "As the manager, do you maintain control and make all decisions?" B: "As the manager, do you assume a passive, nondirective approach?" C: "As the manager, do you facilitate decision making within the group?" D: "As the manager, do you change style according to the needs of the group?"

B

The nurse from the psychiatric unit is reassigned to the pediatric unit. Which client assignment is the mostappropriate for this nurse? A.A preschool-age client diagnosed with Type 1 Diabetes admitted with a blood glucose of 370 mg/dLand reporting thirst and frequent urination. B.A school age client diagnosed with hemophilia requiring discharge instructions about appropriate and safe sports. C.A toddler client with a superficial partial thickness burn to the right thigh who cries and screams whenever the parent tries to leave the room. D.An adolescent client with a newly diagnosed brain tumor reporting headaches and left-sided weakness.

C

Which description by the nurse is a correct explanation of delegation? A.The transfer of responsibility for performance of an activity B.The person's responsibility and accountability for individual actions or omissions C.The active process of directing, guiding, or influencing the outcome of an individual D.The transfer of both accountability and responsibility from one to another

a

A 16 year old patient with cystic fibrosis is admitted with shortness of breath and possible pneumonia. Which nursing intervention is most importantto include in the patient's care? A.Perform postural drainage and chest physiotherapy q4 hours B.Allow the patient to decide whether or not they require aerosol medications C.Place the patient in a private room to prevent risk of further infection D.Plan activities to allow at least 8 hours of uninterrupted sleep

a

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? A)Reminding the patient to change positions slowly B)Assessing the patient for muscle weakness C)Teaching the patient how to collect a 24-hour urine sample D)Revising the patient's plan of care

a

The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to administered. Which action should the nurse take? A.Contact the nursing supervisor B. Administer the dose prescribed C. Hold the medication until the HCP can be contacted D.Administer the recommended dose until the HCP can be located

a

There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room? A.A client with a cough who may have tuberculosis. B.A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C). C.A client with diarrhea caused by C difficile. D.A client with a wound infected with Vancomycin-resistant enterococci (VRE).

a

). The nurse received a change-of-shift report on four assigned clients. What patient should the nurse see FIRST? A. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has a serum potassium level of 5.5 mEq/L B. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of 102.8F, BP 98/66 mmHg, and P 114 bpm C. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who has been crying since recent visitors left D. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting medication for pain rated at a 6 on the 0 - 10 scale.

b

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? A.Repositions side to side every 2 hours B.Elevated the head of bed 60 degrees C.Auscultates the lung field every 4 hours D.Encourages deep breathing exercises every 2 hours

b

A client is found by the RN experiencing a myocardial infarction, what should the nurse administer first? A. Morphine B. Oxygen C. Sublingual Nitroglycerine D. Aspirin 81mg

b

A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action should the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? A.Continually reassure and coach the client B.Administer the prescribed oxygen throughout labor C.Maintain strict asepsis throughout the labor process D.Increase IV fluids if the client complains of feeling thirsty

b

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initialaction? A)Prepare the triage rooms B)Activate the emergency response plan C)Obtain additional supplies from the central supply department D)Obtain additional nursing staff to assist in treating the casualties

b

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A.Obtain a court order for the surgical procedure B.Ask the EMS team to sign the informed consent C.Transport the victim to the operating room for surgery D.Call the police to identify the client and locate the family

c

A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would indicate the task is applicable for the registered nurse? A)Administer oral antidepressants B)Administer a pain killer IM C)Teach the client how to use the meter dose inhaler D)Reinforce tips for stress management with the client

c

A nurse is scheduling a client for diagnostic studies of the gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography

c

A 25 year old client comes to the ED with a laceration to the head. The patient is complaining that he has no feeling in his legs. When assessing the patient he has a respiratory rate of 18, palpable pulses, and a cap refill of 2 seconds. Which category would be assigned to this patient? A.Green B.Red C.Black D.Yellow

d

A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status

d

A student attending University was found unconscious in his dorm room after ingesting a poisonous substance, what is the priority intervention the roommate should take? A. Turn him and try to make him vomit B. Call poison control C. Start CPR D. Remove any foreign material from the mouth

d

After a shift change, you are assigned to care for the following patients. Which patient do you assess first? A.A 60 year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B.A 55 year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C.A 70 year old with pneumonia who needs to be started on intravenous antibiotics D.A 50 year old with asthma who complains of shortness of breath after using a bronchodilator

d

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? A)Analyze the ED response to the mass casualty incident. B)Follow up with survivors to determine the need for additional referrals. C)Initiate critical incident stress debriefing (CISD) for staff members. D)Take inventory and restock the ED with supplies and equipment

d

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client complains about a frequent dry cough. 4. Client says, "I get dizzy sometimes if I stand up fast."

3

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider? 1. Serum potassium is 3.4 mEq/L (3.4 mmol/L). 2. Blood urea nitrogen(BUN)is 9 mg/dL (3.2 mmol/L). 3. Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L). 4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

4

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4

A nurse is planning the client assignments for the night shift. The nursing team includes a registered nurse, a licensed practical nurse, and two unlicensed assistive personnel (UAP). Which duty (or duties) could be delegated to the UAPs? (Select all that apply.) A. Transport a client who has had a stroke to the radiology department for a computed tomography (CT) scan. B. Bathe a 25-year-old client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C. Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate (DNR) order. D. Report to the healthcare provider the fingerstickblood glucose level of 2.72 mmol/L (49 mg/dL) on a newly admitted client. E. Feed a female client who is having her first meal after she experienced a stroke.

ABC

Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions are most appropriate? Select all that apply A. The nurse needs to know the Good Samaritan Act for the state. B. The nurse is not held liable unless there is gross negligence C. After assessing the situation, the nurse can leave to obtain help. D. The nurse can expect compensation for helping. E. The nurse offers to help but cannot insist on helping.

ABE

The postpartum nurse receives report on 4 mother baby-couplets. Which tasks can be delegated to the unlicensed assistive personnel? (Select all that apply) A.Assisting the mother with morning hygiene B.Demonstrating neonate bathing technique C.Documenting intake and output on mother D.Evaluating caregiver interaction with the neonate E.Obtaining an axillary temperature of the neonate F.Swaddling the neonate after diaper changes

ACEF

The nurse receives report on the medical/surgical unit. Which client should the nurse see first? A.A client with an IV of NS at 125/hrcomplaining of slight swelling at the insertion site B.Client 3 days post-op total knee replacement complaining of right calf pain with movement C.Client with a respiratory rate of 24 and an O2 sat of 94% on room air D.A client 12 hours after a hysterectomy reporting nausea

B

What is an important consideration for delegation of care by the nurse when the delegateehas limited knowledge and ability to perform the task? A)Guidance B)Expectation C)Explanation D)Responsibility

a

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initialaction? A.Prepare the triage rooms. B.Activate the emergency response plan. C.Obtain additional supplies from the central supply department. D.Obtain additional nursing staff to assist in treating the casualties.

b

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A.Reassure the patient the ventilator will do the work of breathing for him. B.Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. C.Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning D.Insert an oral airway to prevent the patient from biting on the endotracheal tube

b

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? A.A pregnant woman who exclaims, "My baby is not moving." B.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" C.A young child standing next to an adult family member who is screaming, "I want my mommy!" D.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

b

When caring for a victim of sexual assault, which task is most appropriate for the LPN? A.Assess for injuries B.Provide emotional support and communication C.Call for security D.Collect hair samples, swabs, and fingernail scrapings

b

A nurse notices that the physician has prescribed an unusually large dose of a medication. What is the appropriate nursing action? A.Refuse to administer the medication B.Call the Pharmacist C.Notify the Prescribing Physician D.Administer the Medication

c

A nurse on a medical surgical unit has received the shift change report from the previous night and will care for four clients. Which of the following clients needs should the nurse assign to a UAP? A.Feeding a client who was admitted 24 hr ago with aspiration pneumonia B.Reinforcing teaching with a client who is learning to walk using a cane C.Reapplying a condom catheter for a client who has urinary incontinence D.Applying a sterile dressing to a pressure ulcer

c

A nurse's spouse is scheduled for exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate regarding the spouse's medical record and treatment? A.Because the nurse is an employee, she is allowed to access his chart B.The nurse is allowed to access the chart based on their relationship C.Access to the chart requires a signed release form D.The nurse can ask the surgeon to discuss the outcome

c

A patient is admitted to a Cardiac Stepdown Unit with a diagnosis of Hypokalemia. What intervention should the nurse complete first? A.Administer the clients scheduled dose of Lasix B.Obtain a 12 Lead EKG C.Place the client on a Cardiac Monitor D.Obtain an order for the patient to have a new serum potassium level drawn

c

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpablepulse. Which of the following task is appropriate to delegate to the nursing assistant? A)Assisting with the intubation. B) Placing the defibrillator pads. C) Doing chest compressions. D) Initiating bag valve mask ventilation

c

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A)A middle-aged man with 1 foot trapped under the wreckage B)A crying teenager who is holding pressure on an arm laceration C)A young woman who appears dazed and confused and is shivering D)A screaming middle-aged woman looking frantically for her husband

c

What factors are most important for the nurse to consider when delegating responsibilities? A)Preferences of the clients and staff B)Physical Layout of the unit and client rooms C)Staff member's level of education and expertise D)Client's diagnosis and length of time in the hospital

c

Which task is appropriate for the registered nurse to delegate to the UAP? A.Assist a patient who is postoperative hip replacement to ambulate with their walker for the first time B.Change the disposable tracheostomy cannula for a new postoperative tracheostomy patient if secretions are thick and tenacious C.Obtain a sterile urine sample from a patient with a foleycatheter that is connected to a closed drainage system D.Evaluate a patient's ability to swallow ice after a gastroscopy

c

A medical-surgical staff nurse is floated to the telemetry unit to help with client care. From the list of clients, who would be most appropriate to assign to this nurse? Select all that apply. A.The client admitted with new onset atrial fibrillation (AF) B.The client admitted 1 day ago with a repair of a carotid endarterectomy (CEA) C.The client admitted yesterday with a stable, third-degree heart block awaiting a pacemaker evaluation D.The client admitted during the night with normal sinus rhythm and had a repair of a small bowel obstruction (SBO) E.The client admitted 2 days ago who received tissue plasminogen activator (tPA) for an ischemic stroke, and had laboratory studies and x-rays done

c, d

Criteria can be used to assess co-workers competency for delegation. Which of the following methods can be used to assess the competency of nursing assistant personnel? Select all that apply. a.Micro-managing and being able to step in and take over tasks b.Educating and training for the required role function c.Supervising with periodic review and performance feedback d.Orienting to the job description and evaluating tasks within a designated time frame e.Checking with unlicensed assistant when completing the task to obtain feedback about the patient

c, d, e

Althoughthe client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? A.An unintentional tort B.Assault C.Invasion of Privacy D.Battery

d

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriatelyassign to the licensed practical (vocational) nurse? A.A client who requires a bed bath B.An older client requiring frequent ambulation C.A client who requires hourly vital sign measurements D.A client requiring abdominal wound irrigations and dressing changes every 3 hours

d

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A.A postoperative client preparing for discharge with a new medication B.A client requiring daily dressing changes of a recent surgical incision C.A client scheduled for a chest x-ray after insertion of a nasogastric tube D.A client with asthma who requested breathing treatment during the previous shift

d

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? A.Obtain informed consent from the client for the diagnostic procedure. B.Discuss the need to increase oral fluid intake after the procedure. C.Explain to the client that he or she will have to drink a white, chalky substance. D.Tell the client not to eat or drink anything prior to the procedure.

d

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP), which is the best client for the LPN? A.A client requiring frequent temperature checks B.A client requiring assistance with ambulation every 4 hours C.A client on a mechanical ventilator requiring frequent assessment and suctioning D.A client with a spinal cord injury requiring urinary catheterization every 6 hours

d