NCLEX Leadership

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

2. Report if any client indicates pain. (2. Correct. It is within the scope of practice for the UAP to ask the client if they are experiencing pain. The nurse will then assess the pain. The nurse can delegate, assess, develop a plan of care and evaluate. 1. Incorrect. This is an RN task. The UAP does not have the appropriate education to assess a pressure ulcer. This is not within their scope of practice. 3. Incorrect. The UAP cannot assess or evaluate. This is an RN task. Monitoring the amount of chest tube drainage is an appropriate action for the nurse. The UAP cannot monitor the amount of chest tube drainage. 4. Incorrect. The UAP cannot teach. This is an RN task. The nurse cannot delegate teaching or demonstrating to the UAP. This is the responsibility of the RN.)

Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a PICC line that a client accidentally pulled out.

3. Bolus feeding a client who has a gastrostomy tube. (3. Correct: Bolus feeding by way of a gastrostomy tube would be the best assignment for the LPN/VN. This is a nursing action that can be performed by the LPN/VN and does not require verification nor a co-signature by the RN. 1. Incorrect: The LPN/VN can collect data on a new client, but the RN must verify the information and co-sign the assessment. New admits require initial observation and data collection. From this, the RN must evaluate the information and formulate priorities of care. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN. Therefore, this task should not be assigned to the LPN/VN. 4. Incorrect: Reinserting a PICC line is out of the realm of practice for an LPN/VN. Therefore, this task should not be assigned to the LPN/VN.)

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.

3. Feed a child with bilateral burns of hands. 5. Ambulate an adolescent two days post appendectomy. (3. & 5. Correct: A UAP can perform any activities of daily living (ADL), including transfers in or out of bed and ambulation. Feeding clients is considered an ADL which can be performed by a UAP, so feeding a child whose hands are bandaged is an appropriate task. Also, ambulating the adolescent is definitely within the scope of duties for the UAP. 1. Incorrect: Obtaining a urine sample from an infant is too complex for a UAP. The two methods used for collecting this urine sample is either straight catheterization of the infant or use a "wee bag". Neither of these methods can be performed by a UAP. 2. Incorrect: Emptying containers can be within the realm of duties for a UAP. However, that does not include a NG canister. A nurse must assess the color, consistency, and amount of drainage in the canister in addition to location and position of the NG tube. This particular action should be completed by a nurse. 4. Incorrect: Changing an ostomy appliance is a complex task. A nurse needs to assess the skin for evidence of skin breakdown or excoriation that needs treated before another flange is applied. The nurse must also assess the condition of the stoma. This is not a task appropriate for a UAP, although emptying the ostomy bag would be appropriate.)

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

3. Safe home environment. (3. Correct: The most critical assessment is to make sure that the client is going home to a safe environment. Then the other assessments could be made. Without a safe environment the client does not need to go home. Information about electrical wiring, back-up power, hygiene and infection control needs all provide a safe environment for this client. 1. Incorrect: This is not the most critical assessment and can be done after making certain the client will be safe. Remember Maslow's Hierarchy of Needs. After you determine needed resources (#4) then financial stability would be next. 2. Incorrect: Long term goals are very important but we are worried about short term needs right now. Remember in a priority question all options are plausible but only one is critical now. 4. Incorrect: Once the environment is considered safe for the needed or required care of the client, then the needed equipment would be next.)

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5. Monitor for behavioral changes. 6. Check environment for potential safety hazards. (5. & 6. Correct: The LPN/VN can monitor for behavioral changes and can look for potential safety hazards. 1. Incorrect: The RN is responsible for teaching. This task cannot be delegated to the LPN/N. The LPN/VN can reinforce teaching. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. The LPN/VN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 3. Incorrect:The RN is responsible for developing the plan of care which would include necessary referrals. 4. Incorrect: This again is assessment which is the role of the RN only.)

In what order should the home health nurse see assigned clients? Place in priority order. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with rheumatoid arthritis who requires an occupational consult. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information.

Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Client diagnosed with rheumatoid arthritis who requires an occupational consult. (The first client the nurse needs to assess is the one diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. The nurse needs to determine if this client has a plan to carry out the threat of suicide. This situation is life threatening. The second client that should be assessed by the nurse is the client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Consider this client a new admit who requires an assessment and plan of care to be developed. The third client that should be assessed by the nurse is the client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Assessing this client and educating family about hospice care can be done after the more critical issues with the other two clients are taken care of. There is no indication that this client is unstable, so the nurse can see this client third. Lastly, the nurse should assess the client diagnosed with rheumatoid arthritis who requires an occupational consult. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This consult can be done after caring for the clients who are less stable and require greater care.)

The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients? The client with facial burns 3 days ago who has been crying since recent visitors left. The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L.

The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. The client with facial burns 3 days ago who has been crying since recent visitors left. (The nurse should first see is the client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. This client has a fever and hypotension, indicative of life threatening complications of shock. In this case, septic shock. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L should be seen second. This client is at risk for heart problems (dysrhythmias) with the electrical burn and the elevated potassium level. The third client the nurse should see is the client reporting pain 7/10. The nurse needs to administer pain medication. However, remember that pain never killed anyone. Take care of the other two client first. This are at risk for death. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the most stable.)

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? Select all that apply 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.

4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour. (4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.)

A nurse manager has recognized that nurses on one shift do not seem to be working well together and, on occasions, refuse to help each other when needed. What strategy could the nurse manager use that would help with team building? Select all that apply 1. Avoid discussing conflicts to build a positive work environment. 2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication.

2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication. (2., 3., 4., 5., and 6. Correct: The nurse manager needs to incorporate strategies that are effective in team building. One important thing that a nurse manager can do when trying to get nurses to work as a team is to actually model behaviors that promote trust and create a caring environment for not only the clients, but also the nurses and other staff as well. Trust is a cornerstone when trying to build team relationships. In order for nurses to recognize a need for teamwork and reduce conflict, they should have a clear understanding of the unit and agency mission and purpose. The unit manager should assure that this is clearly documented and articulated to the nurses and staff on the unit. The nurse manager should help each nurse and staff member understand how they fit into the overall purpose and goals of the unit and agency. We all know that recognition tends to foster positive behaviors. The nurse manager should recognize nurses who demonstrate commitment to team efforts. This can be done with tangible or nontangible rewards. So, why should nurses be made aware of the messages being sent to the other team members by their behaviors? These nurses may not realize how their unwillingness to work as a team negatively impacts the healthcare team as a whole. They may think that as long as they take care of their clients the way that they want to, everything should be fine. Nurse managers can help nurses to see how their behaviors affect client care and team relations. Once the nurses have agreed upon the roles and responsibilities as part of the healthcare team and understand the lines of communication, they are more likely to follow through with these. Communication by the nurse manager will be crucial in carrying out this team building strategy where all team members agree upon what needs to be accomplished and who to communicate with along the way. 1. Incorrect: It is the nurse manager's responsibility to address the conflict and issues that arise. Failure of the nurse manager to address conflicts within the workplace often fuels more conflict. In addition, the team members often lose respect for the nurse manager who does not discuss and help to resolve the issues. Conflict avoidance can have long term effects on the nursing unit and the agency and can stifle productivity and success of the unit.)

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 5. Alert all off-duty personnel to stand by in case of call- in. (2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 1. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.)

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? Select all that apply 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. (3., 4. & 5. Correct: It is within the role of the UAP to assist a client with a walker. The UAP can collect and calculate intake and output. When assisting the client with hygiene needs, the UAP can promote strengthening of the affected side by encouraging and assisting the client to place the hairbrush in the hand of the affected side. 1. Incorrect: The UAP cannot assess a client. Assessment is not in role of the UAP and is also outside the scope of practice for LPN's. Assessments must be performed by the RN. 2. Incorrect: Although the UAP can provide care and assistance related to hygiene needs, the planning of care cannot be delegated to the UAP. This is part of the nursing process and must be performed by the RN. 6. Incorrect: Teaching cannot be delegated to the UAP and is also outside the scope of practice for the LPN. Teaching is a responsibility and in the scope of practice for the RN.)

When making assignments for an LPN on the Labor and Delivery unit, the charge nurse is aware the most appropriate clients should meet what criteria? 1. Clients requiring close monitoring. 2. Post-vaginal delivery clients only. 3. Clients with a predictable outcome. 4. Non-routine clients in early labor.

3. Clients with a predictable outcome. (3. Correct: A client with a predictable outcome is stable enough to be assigned to the licensed practical nurse (LPN). If complications should arise, the LPN would report this to the registered nurse. 1. Incorrect: Clients requiring close monitoring indicate an unstable or unpredictable status, which is not an appropriate assignment for the LPN. These clients should be assigned to a registered nurse. 2. Incorrect: The manner of delivery a client experienced does not dictate which staff personnel are able to provide care. More important factors would focus on whether the client had a non-eventful delivery or suffered any unexpected complications. 4. Incorrect: The term "non-routine" immediately indicates an unstable client with potential problems that need frequent assessment. An LPN should only be assigned to those stable clients with expected or predictable outcomes.)

A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the RN delegate to an unlicensed assistive personnel (UAP)? 1. Reminding the client to apply the CPAP at bedtime 2. Obtaining oxygen saturation levels every three hours 3. Teaching the client how to turn on the CPAP machine 4. Assessing for fatigue or depression caused by poor sleep

1. Reminding the client to apply the CPAP at bedtime (1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. The UAP cannot perform actual teaching because this is outside the scope of practice, but reminding the client about what was taught may help with compliance. 2. Incorrect: This is an assessment function and may be outside the UAP's scope of practice in some states. Since oxygen saturation requires every three hour monitoring, it is best not to assign this to the UAP. The nurse should be the one to check the oxygen saturation levels every three hours because additional assessment of the client status may be warranted. 3. Incorrect: Initial teaching about the CPAP machine is the responsibility of the RN. The LPN can reinforce this teaching, but teaching is outside the UAP's scope of practice. 4. Incorrect: Assessment is outside the UAP's scope of practice. Independent assessment requires additional education and skills and should be carried out by the RN.)

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Discuss the issue with the leader of the "best practices" committee. (2. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. An experienced person who can research "best practice" regarding the issue is needed. The best practice committee works to improve clinical practice based on current research. 1. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. The best practice committee utilizes current research in their recommendations. 3. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. The nurse could definitely be part of the committee. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 4. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. The primary healthcare provider may have suggestions but this is not the best first action.)

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Ask the RN why the assignment is too heavy. (3. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The charge nurse needs additional information to make a decision. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. 1. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. The charge nurse's best response is to first obtain the needed information to make the best decision. 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. The situation should be explored before bringing the supervisor in on the situation. 4. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Something new could have occurred with the clients, making the assignments too heavy. The charge nurse might not have realized all the responsibilities of taking this team of clients. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients.)

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? 1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours. (4. Correct: The LPN/VN can administer subcutaneously medications. 1. Incorrect: This is an RN only responsibility and cannot be delegated. 2. Incorrect: The unlicensed assistive personnel (UAP) can be assigned to place equipment in a client's room. 3. Incorrect: Passive ROM exercises can be done by the UAP.)

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings. (3., 4. & 5. Correct: It is within the role of an UAP to empty the indwelling catheter bag, assist with position change and apply anti-embolism stockings. The nurse should confirm that these tasks have been done, but they are safe to delegate to the UAP. 1. Incorrect: This is a task for the RN and involves teaching and evaluation of effectiveness. 2. Incorrect: The physical therapist is the best team member to manage the TENS unit since this is a pain control device that affects nerves and muscles.)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

3. Reapply pneumatic compression device to client's legs. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours. (3., 5., & 6. Correct: The UAP is trained on use of routine equipment such as pneumatic compression devices and can reapply the device to a client. Gathering needed equipment and supplies is within the scope of duties for the UAP. Repositioning a client every 2 hours is within the UAP's ability and can be assigned by the nurse. 1. Incorrect: The UAP can provide routine hygiene. The nurse would be responsible for wound care, including halo insertion pin site care. This requires skill beyond the UAP's knowledge. 2. Incorrect: The UAP cannot administer medications. 4. Incorrect: The UAP cannot assess or evaluate a client. The RN most do this part of the nursing process.)

The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. What action should the nurse implement first to ensure client safety? 1. Take report on the most critical clients first. 2. Encourage the staff to help each other. 3. Assign one additional client to each nurse. 4. Call the nursing supervisor to request additional staff immediately.

4. Call the nursing supervisor to request additional staff immediately. (4. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. The nurse should call for immediate help so that a safe care environment is maintained for all clients. The charge nurse should notify the nursing supervisor who will seek additional staff. The nursing supervisor may be able to assist with client care until another nurse can come in to work. 1. Incorrect: The critical clients are important, but all clients must be considered. The charge nurse must evaluate each client's status and needs to assign the appropriate staff to care for them. The safety of each client must be reviewed. 2. Incorrect: The charge nurse may encourage the staff to work together. This is a positive action but the priority for the charge nurse is to ask for additional staff to maintain safe nursing care. 3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing can be obtained. However, calling the nursing supervisor to request help is the first action.)

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin. (4. Correct: This client is demonstrating signs of a heat stroke. This client would be a priority due to the severity of dehydration as evidenced by the altered mental status, poor muscle coordination, and absence of sweating. 1. Incorrect: This elderly client is probably dehydrated and may have experienced some postural hypotension while working in the yard which could play a role in the syncope. This client will need a workup to rule out other underlying issues. However, this client would not be a priority over the client with altered mental status. 2. Incorrect: It is not uncommon for athletes to experience heat related dehydration with muscle cramps, nausea, tachycardia, and diaphoresis. This should be managed with fluid and electrolyte replacement. This client still has diaphoresis, which makes the client less a priority than the client who no longer is producing sweat. 3. Incorrect: This client is showing signs of heat exhaustion with dehydration. However, this client continues to have diaphoresis, which makes this client less of a priority to see than the client who no longer has diaphoresis and has altered mental status.)

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 6. Provide mandatory in-service sessions on infection control for every shift. (1., 2., 3., 4., & 6. Correct. Each of these actions can be taken by the nurse manager. The staff needs further education, reminders, and follow-up observation. Posters are great reminders of concepts. All nurses need to supervise those under their direction. Testing can be done as pretest or post test along with in service education. Staff development or in service sessions are required by Joint Commission on Accreditation of Healthcare Organizations (JCHO) on infection control. 5. Incorrect. This is not the best solution, because most people want to do what is right. Education should be tried first, then documentation of the infractions. You must support, supervise, and educate.)

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk. Client diagnosed with cancer who is crying and states, "I am not ready to die". Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Client one day post splenectomy.

Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Client one day post splenectomy. Client diagnosed with cancer who is crying and states, "I am not ready to die". Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk. (The first client the nurse needs to assess is the one admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection. This client will likely need blood cultures and antibiotics quickly. The second client that should be assessed by the nurse is the client who is one day post splenectomy. There is no indication that this client is in any immediate danger, but as a surgical client one day postop, this client should be assessed prior to moving on to the other three clients. The nurse needs to assess for any possible complications associated with surgery. The third client the nurse needs to see is the client diagnosed with cancer who is crying and states, "I am not ready to die". This client is facing death and is exhibiting grief. The role of the nurse is to respond appropriately to the client's needs by listening carefully and addressing the social, emotional and spiritual aspects of the client's symptoms. This client should be seen after clients who have a physical problem that could be life threatening. The fourth client the nurse should assess is the client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. This client does not need immediate care. The nurse needs to talk to the client about why the client is refusing chemotherapy and if any education or referrals are needed. Clients who are stable and awaiting discharge teaching can be seen last.)

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. Client with traumatic amputations with agonal respirations. Client with blunt trauma to the spine that is unable to move extremities. Client with an open chest wound that is beginning to show signs of tracheal deviation. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding.

Client with an open chest wound that is beginning to show signs of tracheal deviation. Client with blunt trauma to the spine that is unable to move extremities. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. Client with traumatic amputations with agonal respirations. (The client with an open chest wound should be seen first. This client is one whose life could potentially be spared if lifesaving measures are taken. This client may be developing a tension pneumothorax and may need an immediate needle decompression. The client would also need a dressing that is taped down on 3 sides applied over the open chest wound. The second client to be seen is the one with blunt trauma to the spine. Although this client needs emergency treatment as soon as possible due to having probable spinal injury with paralysis, this client's condition is not likely to deteriorate as fast as the client with the open chest wound who is developing a tension pneumothorax. The third client to be assess by the nurse should be the client with the laceration. Did you see laceration with bleeding and think that something would have to be done immediately? Well, there is only moderate bleeding, so although this client needs obvious treatment, this client can wait and would not be a priority over the clients with the open chest wound and blunt trauma to the spine. The last client to be assessed should be the client with agonal respirations. Although this client is still alive, during a mass casualty, the nurse would recognize that the client has agonal respirations and would not have a very good chance of survival with intervention. This client would not take priority over a critical client who has a better chance of survival.)

What clients could safely be delegated to the LPN/VN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction. (1, 2, 5 & 6. Correct: Thes clients are appropriate and stable enough for the LPN/VN's scope of practice. While an LPN/VN cannot be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/VN could even delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need a respiratory assessment by the RN at some point, but the LPN/VN is definitely qualified to administer aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no injuries serious enough for a full admission. PNs can insert and monitor NG tubes. 3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about selfcare at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an LPN/VN. This option does not indicate that any teaching had been presented, so the client is not an appropriate assignment for the LPN/VN. 4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need for close monitoring and frequent assessment of the respiratory system, requiring an RN.)

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? Select all that apply 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1. A client with COPD complaining of shortness of breath on exertion. 3. A client receiving heparin injections for deep vein thrombosis. 5. A client receiving a blood transfusion that requires monitoring. (1, 3 & 5. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Client #5 -It is considered within the scope of practice for an LPN/VN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catherization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 4. Incorrect: Atrial fibrillation places the client at risk for blood clots. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assessing this client and titrating the diltiazem requires the skills of an RN. 6. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. These areas require the expertise of an RN and would not be appropriate for an LPN/VN.)

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? Select all that apply 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1. Child with superficial burns on both upper arms. 3. Crying toddler missing both upper front teeth. (1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. However, providing care for missing teeth would also be within the LPN scope of practice. 2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen and internal bleeding. This adolescent will require further tests, such as CT scan, and possibly emergency surgery. Because of the complexity of the situation, an RN should be assigned this client. 4. Incorrect: Since these clients were injured during the hurricane, the charge nurse must assume the worst. This client is reporting headache and diplopia; therefore, a safe nurse would consider the possibility of head trauma with brain swelling accounting for the blurred vision. Such potential makes this client serious to critical, and as such, should be assigned to an RN for on-going neurologic assessment. 5. Incorrect: While the trauma of a hurricane could adversely affect the digestive system, the charge nurse would assume the worst and suspect the likelihood the client is having a myocardial infarction. Only an RN can complete the appropriate assessment, testing, and other needs expected with an MI client.)

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care? 1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

1. Identify community services available for the client and family. (1. Correct: The nurse promotes continuity of care at discharge by providing a smooth transition from one level of care to another. The nurse should include in the discharge plan appropriate community support services available to the client and family so that they can obtain support as needed. 2. Incorrect: This may be premature at this point. Hospice referral is provided when any person with a life threatening illness, which measures life in months rather than years, qualifies for hospice care. 3. Incorrect: It is not appropriate for the nurse to impose personal opinions about what is best for the client. 4. Incorrect: This may be premature at this point. Further assessment is needed and can be provided as the cancer progresses.)

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

1. Interrupt the staff nurse and complete the discharge. (1. Correct: The charge nurse should make sure that professional boundaries are maintained; therefore, the charge nurse should interrupt the process and continue with the discharge procedure. Then the nurse should be counseled immediately so that further inappropriate behavior does not occur. 2. Incorrect: The nurse should be counseled; however, counseling does not need to be done in front of the client. The better option is to counsel the staff nurse in private. 3. Incorrect: The charge nurse must make sure that professional boundaries are maintained. To make no comment indicates acceptance of the behavior. 4. Incorrect: No, the charge nurse interrupts the staff nurse and completes the discharge then counsels the staff nurse on professional boundaries.)

What action should the nurse take after mistakenly administering the wrong medication? Select all that apply 1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. 5. Document medication error and incident (variance) report in nurse's notes.

1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. (1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Documentation of what occurred, and the client's assessment is required in the nurse's notes. 5. Incorrect: Do not document that an error was made or that an incident (variance) report was completed. Document what medication was given, the client's assessment, the notification of the nursing supervisor, and primary healthcare provider, and any prescriptions received.)

The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which response by the LPN is appropriate in response to the inappropriate delegation? 1. Notify the primary healthcare provider. 2. Refuse the delegated intervention. 3. Discuss the assignment with another LPN. 4. Ask the charge nurse to evaluate the intervention.

1. Notify the primary healthcare provider. (1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. The UAP cannot perform actual teaching because this is outside the scope of practice, but reminding the client about what was taught may help with compliance. 2. Incorrect: This is an assessment function and may be outside the UAP's scope of practice in some states. Since oxygen saturation requires every three hour monitoring, it is best not to assign this to the UAP. The nurse should be the one to check the oxygen saturation levels every three hours because additional assessment of the client status may be warranted. 3. Incorrect: Initial teaching about the CPAP machine is the responsibility of the RN. The LPN can reinforce this teaching, but teaching is outside the UAP's scope of practice. 4. Incorrect: Assessment is outside the UAP's scope of practice. Independent assessment requires additional education and skills and should be carried out by the RN.)

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

1. Occupational therapist (1. Correct: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help clients improve their ability to perform activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals. 2. Incorrect: The physical therapist is trained to deal with problems that limit their abilities to move, perform daily functions, or remain active and independent. However, physical therapists do not assist with special adaptations needed to perform activities of daily living such as eating. 3. Incorrect: A rehabilitation nurse can help a client eat, but isn't trained in modifying utensils. The rehabilitation nurse assists clients as they adapt to altered lifestyles and assists clients to attain and maintain the highest level of functioning. Some of the aspects included in the role of the rehab nurse includes encouraging self care, preventing complications and further disability, setting goals for independent functioning, and assisting clients to access additional care needed. The rehabilitation nurse would work collaboratively with the occupational therapist (OT). The OT is the one who will best meet the needs of this client who is experiencing difficulty eating with regular utensils. 4. Incorrect: A registered dietitian manages and plans for the nutritional needs of clients but isn't trained in modifying or fitting utensils with assistive devices. This would be the role of the OT.)

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Replace soiled heel protectors on bedfast client. 2. Provide TUMS to client reporting heartburn. 3. Trim fingernails on confused diabetic client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list.

1. Replace soiled heel protectors on bedfast client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list. (1, 4 & 5.Correct: The tasks appropriate for the unlicensed assistive personnel (UAP) focus on activities of daily living. Replacing any item of clothing, including heel protectors, is appropriate for the UAP. Ambulating a client outside is an excellent activity to delegate to the UAP, in addition to helping a client complete the diet menu. The UAP can read the selections to the client and mark the choice. 2. Incorrect: When a client reports heartburn, there are potential issues requiring assessment by the RN. The client may actually be experiencing a cardiac event which would require intervention and contacting the primary healthcare provider. Though TUMS is an over the counter product, it is still considered a medication and should be administered nursing staff. 3. Incorrect: Although trimming nails is usually an acceptable task to delegate, diabetics need close assessment as well as specific shaping techniques for nails. This responsibility involves assessing and must be delegated to nursing staff.)

Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Select all that apply 1. Talk to each nurse about concerns related to assigned clients. 2. Call the family of a client suffering from dementia to discuss long term care placement. 3. Briefly assess every client. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client.

1. Talk to each nurse about concerns related to assigned clients. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client. (1., 4., & 5. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. 2. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 3. Incorrect: The charge nurse does not have to assess every client. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift.)

Which nurse would be the most appropriate for the charge nurse to assign to a 5 year old admitted in sickle cell crisis? 1. The nurse who is taking care of a 4 year old who had a routine appendectomy, a 3 year old who had bowel surgery, and a 10 year old with developmental delays. 2. The nurse who is taking care of a 6 month old with Respiratory Syncytial Virus (RSV), a 3 year old with exacerbation of asthma, and a 6 year old with a urinary tract infection for 2 weeks. 3. The nurse taking care of a 9 year old newly diagnosed with diabetes, a 6 year old with end stage renal disease, and a 2 year old with contact dermatitis. 4. The nurse taking care of a 8 year old with skeletal traction, a 5 year old with cerebral palsy, and a 12 year old with cystic fibrosis.

1. The nurse who is taking care of a 4 year old who had a routine appendectomy, a 3 year old who had bowel surgery, and a 10 year old with developmental delays. (1. Correct: The nurse taking care of the appendectomy, bowel surgery, and developmentally delayed child has the set of clients that is less busy and has fewer client care needs. Routine appendectomy and bowel surgery will need observation and assessment but should be stable. The child with developmental delays will need assistance but no life threatening concerns with any of these clients. 2. Incorrect: This set of clients are not appropriate primarily, because of the RSV client. The client with sickle cell already has an oxygen problem and does not need RSV too. RSV is very contagious. 3. Incorrect: This set of clients are very labor intensive. The newly diagnosed diabetic requires constant assessment and interventions to prevent complications. The 6 year old with end stage renal disease also will require a great deal of nursing assessment. 4. Incorrect: Assignment requires much care for clients. This set of clients are inappropriate because of the labor intensive needs. Skeletal traction will require pin care, skin care and prevention of immobility. The cerebral palsy client will require assistance with hygiene and self care and the cystic fibrosis client requires respiratory and GI care including assessment fro complications.)

The nurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

2. A client with epilepsy reporting an odd smell in the room. (2. Correct: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. Incorrect: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. This client is not the nurse's first priority. 3. Incorrect: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 4. Incorrect: There is no information regarding how recent was the surgery or the degree of pain being experienced. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority.)

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? 1. Assist with bottle feeding newborns in the nursery. 2. Completing perineal care for post-delivery clients. 3. Observing a Cesarean section for co-joined twins. 4. Ambulate client to bathroom following delivery.

2. Completing perineal care for post-delivery clients. (2. Correct: The general scope of practice for a licensed practical nurse (LPN) includes the completion of tasks with predictable outcomes. Completing perineal care is definitely within the LPN's scope of practice. If any irregularities are noted, such as amount or color of drainage, the LPN would report this to the RN for further assessment. 1. Incorrect: Although bottle feeding may sound like a simple task, there are multiple on-going assessments involved with newborns. A nurse must evaluate whether the infant can latch on, has an appropriate sucking reflex, or if the newborn displays any allergic reactions to the milk. This task should be designated to an experienced nurse rather than the LPN. 3. Incorrect: While it is not inappropriate for a newly hired LPN to observe this unique surgery, it would not help orient or prepare the individual for working on the unit. The LPN should be preparing for other duties or working with a preceptor to learn the floor routine. 4. Incorrect: A number of staff members could ambulate clients to the bathroom, including the LPN or unlicensed assistive personnel (UAP). This task could easily be designated to the UAP, allowing the charge nurse to better utilize the LPN's abilities within the scope of practice.)

Several clients have reported to the charge nurse that they are not receiving pain relief when a certain RN administers their pain medication. The charge nurse has noticed that the RN has been looking unkempt in appearance and seems to be in a daze much of the time. What is the most appropriate action for the charge nurse to take? 1. Lessen the nurse's client assignment to see if things improve. 2. Discuss the concerns directly with the nurse. 3. Give the nurse a 6 month period to be observed. 4. Avoid confronting the nurse so that the client's care will not be jeopardized.

2. Discuss the concerns directly with the nurse. (2. Correct: This may be a situation in which the charge nurse must address the issue of an impaired nurse. All nurses should be aware of the signs and symptoms of substance abuse. The best way for the charge nurse to deal with these suspicions initially is to directly discuss the concerns with the nurse. Intervention may be needed immediately to protect the safety of the clients. If deemed appropriate, the charge nurse may encourage the nurse to seek help independently. 1. Incorrect: This action will not do anything to help an impaired nurse. In fact, this could potentially put the few clients being cared for by this nurse at risk of harmful actions, and it could create an unsafe workload on the other nurses who would be picking up additional clients that this nurse was no longer caring for. 3. Incorrect: Impaired nurses can lose their usual ability to provide safe, competent client care. Although nurses may be working under the influence of a substance, they retain accountability for their actions and cannot use impairment as a legal defense if harm occurs to a client. So we should certainly not allow the nurse to continue working without investigation and/or intervention. 4. Incorrect: Avoiding confrontation with the nurse will not help to fix this problem. Although it can be very difficult to suspect a co-worker of being impaired or abusing substances, especially when fear of retaliation may be present, nurses should know that they have a responsibility to report any suspicion of such activity to nursing management.)

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? Select all that apply 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 6. Hyperphosphatemia (2., 3., 4., & 6. Correct: When the cells are destroyed or lyse from the chemotherapy, there is a release of potassium and phosphates from the cells. Therefore, hyperkalemia and hyperphosphatemia are direct results of the cellular destruction. Purines are also released during cellular destruction. The purines are metabolized and converted to uric acid, which leads to hyperuricemia. Phosphorus and calcium have inverse relationships. If the phosphorus is high, the calcium will be low. 1. Incorrect: Although clients who are on chemotherapy often have thrombocytopenia, or low platelet counts, this is not a hallmark sign of tumor lysis syndrome. 5. Incorrect: Hypomagnesemia is not a hallmark sign of the tumor lysis syndrome. However, as uric acid levels increase from the cellular lysis, the uric acid crystals can create a mechanical obstruction in the renal tubules of the kidneys and lead to acute kidney injury. If the kidneys are not working properly, will magnesium be excreted properly? No! Therefore, a later finding of the kidney injury could be hypermagnesemia, not hypomagnesemia.)

The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 1. Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. 2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. 4. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. (2. Correct: Obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPN/VN. 1. Incorrect: The ED is not staffed to care for a client in labor. The client should be transferred to the labor and delivery unit. The change nurse would then make the appropriate nurse assignment. 3. Incorrect: LPN/VNs are not qualified to perform the initial assessments. 4. Incorrect: At least, baseline data should be obtained on this client (vital signs, fetal heart and contraction patterns). Someone must assume care of the client and the LPN/VN can obtain the vital signs and connect the client to the fetal monitor.)

The day shift nurse in a long-term care facility has been noticing that the adult brief on a total-care client has not been changed since the previous day's shift and perineal care has not been provided, despite the brief being full with urine and feces. The client's perineal area is becoming excoriated from the contact with excrements. The nurse has spoken with the night shift nurse on 2 occasions about the concerns and was told by the night shift nurse that she takes care of the clients and to stay out of her business. What action should the day shift nurse take next? 1. Avoid reporting the night shift nurse to prevent job loss or disciplinary actions. 2. Report the client findings and previous discussions to the charge nurse. 3. Notify the agency attorney of the breach in care being provided. 4. Tell the client's family that they should report the night shift nurse.

2. Report the client findings and previous discussions to the charge nurse. (2. Correct: You notice in the stem that the day shift nurse has already taken the first step, which was to discuss the ethical issue with the night shift nurse involved. Since no corrective measures have been taken, the day shift nurse has an ethical obligation to the client to now report this situation to the charge nurse. 1. Incorrect: Staying silent will not protect the client, who is the one that the day shift nurse has an ethical obligation to protect. Although the day shift nurse may not want to see the night shift nurse disciplined or terminated, the focus should remain on protecting the client from harm. 3. Incorrect: Although the agency attorney may become involved at some point, the charge nurse would be the next person in the chain of command to report this situation to. 4. Incorrect: Telling the family to report the night shift nurse would be inappropriately shifting the ethical obligation of the nurse to report the situation. This could also create some legal problems that could be avoided by appropriate reporting by the nurse.)

The nurse manager is developing a new yearly evaluation form for the staff. What statement(s) by the nurse manager would most likely improve staff outcomes? Select all that apply 1. "How often do you need help to finish assignments?" 2. "Are there any new skills you feel capable to learn?" 3. "Describe how you organize your daily assignments." 4. "Which tasks are most difficult for you to complete?" 5. "Explain any new goals you would like to achieve."

3. "Describe how you organize your daily assignments." 5. "Explain any new goals you would like to achieve." (3 & 5. Correct: Positive outcomes are more likely when staff feels appreciated, receiving constructive and encouraging feedback on a regular basis. Evaluations can be very stressful when staff are uncertain of expectations or are perceived in a negative framework. Seeking clarification on how staff organize assignments indicates awareness and may help in developing new protocols. Also, showing interest in individual goals will help develop learning opportunities for all staff. 1. Incorrect The tone of this question is derogatory, implying the individual is not able to complete daily assignments in a timely manner without assistance. 2. Incorrect: This inquiry is worded in a negative manner, implying the individual may not have the ability to learn new skills. 4. Incorrect: Although this might present information the nurse manager might use to develop more learning opportunities, the negative approach may intimidate staff, preventing complete honesty.)

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3. "Unexpected changes can be difficult to accept." (3. Correct:The nurse manager should utilize therapeutic techniques with staff as well as clients. The introduction of new equipment, particularly with no staff input, can cause frustration, job dissatisfaction, or even anger. Open-ended statements and questions allow staff to verbalize emotions in a situation which has led to feelings of powerlessness. This approach by the nurse manager will help staff adapt more successfully to this situation. 1. Incorrect: This closed, antagonistic remark is accusatory and provides no opportunity for staff interaction. The nurse manager has responded by placing blame on the staff instead of encouraging the expression of feelings and frustrations. 2. Incorrect: Such a comment focuses on training or lack of staff knowledge regarding the new equipment. This is a closed-ended comment which focuses on the issue of staff learning rather than lack of input for the equipment. 4. Incorrect: Though the comment may seem encouraging, the nurse manager is ignoring the staff's feelings and implying everything will be okay. This belittles staff emotions and is closed-ended, eliminating the opportunity to work through feelings.)

The nurse has received the change-of-shift report. What client should the nurse assess first? 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

3. A client with a fractured right humerus who reports the cast is too tight. (3. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Compartment syndrome could be developing which can impede circulation and cause nerve damage. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 1. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. 2. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 4. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? No! However, it remains true pain for this client and the client would need intervention to help manage this pain. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome.)

The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is most appropriate for the new nurse? 1. A gravida 3 para 2 in active phase of stage one, expecting twins. 2. A gravida 2 para 0 at 41 weeks gestation, awaiting induction. 3. A primigravida in active phase of stage one, waiting for epidural. 4. A 12-hour post Cesarean section needing assistance to ambulate.

3. A primigravida in active phase of stage one, waiting for epidural. (3. Correct: The primigravida presents many opportunities for basic and diverse skills that would be very educational for the new nurse. This is the most appropriate client and will provide a good experience in basic labor and delivery procedures. 1. Incorrect: While this may seem like an interesting case, there is the potential for several problems. A third pregnancy generally proceeds faster, and this client is expecting multiple births. This case can quickly become too complicated for a new nurse. 2. Incorrect: Although this may seem like an interesting case for the new nurse, induction of labor can lead to many problems which could be too complicated for this new nurse. This client requires close monitoring during the induction and would not be the best choice here. 4. Incorrect: Ambulating a post-C-section for the first time would be within the level of competency for a new nurse. However, there is very little educational value in this assignment and it is important to provide learning opportunities for this new nurse.)

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? Select all that apply 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3. Assessment of newly admitted clients. 5. Teaching the diabetic client foot care. (3. & 5. Correct: Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN. These are tasks that must be performed by the RN. The LPN can reinforce teaching. 1. Incorrect: Medication administration is within the LPN scope of practice and can be completed by the LPN. 2. Incorrect: Dressing changes may be delegated to the LPN as this is within the LPN scope of practice. 4. Incorrect: The LPN may call lab results to the primary healthcare provider because this is within the scope of practice for the LPN. If any additional prescriptions are required, the LPN can take these prescriptions over the phone.)

The charge nurse has received word that a mass casualty has occurred and beds are needed in the hospital. This will require discharging some current clients. Which client would be appropriate to seek permission from the healthcare provider to be discharged? Select all that apply 1. Client admitted with chest pain and has an elevated Troponin level. 2. Client with blood glucose of 500 mg/dL and pH of 7.3 receiving IV insulin. 3. Client admitted with hemothorax but no chest tube drainage in last 14 hours. 4. Client who underwent a laminectomy for spinal stenosis 12 hours earlier. 5. Elderly client who fell and is developing increased confusion.

3. Client admitted with hemothorax but no chest tube drainage in last 14 hours. 4. Client who underwent a laminectomy for spinal stenosis 12 hours earlier. (3., and 4. Correct: These clients are the ones that would be considered the most stable and therefore, could be safely discharged. The client who had the hemothorax and has not had any drainage for 14 hours indicates that the hemothorax has resolved. The chest tube could be safely removed for the client to be discharged. Clients who have laminectomies often are released home the same day as the surgery, if there are no complications and the condition is stable. This may seem early to discharge a client who had back surgery, but the clients who need to be admitted would be considered unstable and would be a priority over this client. 1. Incorrect: This client would be considered unstable and therefore not a candidate for discharge. This client may be having a MI as indicated by the presence of chest pains and the elevated Troponin level. Remember, Troponin is one of the most specific cardiac biomarkers for indicating myocardial damage. 2. Incorrect: This client is in diabetic ketoacidosis (DKA) and considered unstable. This client is in need of continued IV insulin and careful monitoring. Metabolic acidosis is an unstable condition. 5. Incorrect: Although you may think that it is normal for the elderly to have some confusion, this client may have a cerebral bleed following the fall and is considered unstable. If the client is found to not have a bleed or other complication from the fall and is determined to be stable, this would be the next client who would be considered for discharge.)

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

3. Discussing client with staff not providing direct care. (3. Correct: The most common violation of HIPAA privacy regulations occurs when healthcare workers discuss a client with those not directly involved in the care of the client, including other staff members. Those working in a facility are not entitled to have access to client health data unless providing direct care to that client. 1. Incorrect: Exposing more of the client than necessary during a bed bath is definitely considered a violation of privacy. However, the graduates are to select the most common situation, and bed bath issues are less common. 2. Incorrect: Leaving a client's chart open in full view of staff and visitors does violate a client's privacy. But, such a problem is not as common as another situation. 4. Incorrect: The problem of overhearing conversations may occur in facilities where multiple clients share the same room or in an emergency room where only a curtain exists between clients. Pulling the curtain does not guarantee that voices will not carry, though most primary healthcare providers try keep voice levels at a minimum.)

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to obtain clients vital signs and a weight. 2. Assign an LPN/VN to perform the initial nursing history and physical assessment. 3. Have an LPN/VN perform collect data on the client and report results to RN. 4. Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible.

3. Have an LPN/VN perform collect data on the client and report results to RN. (3. Correct: The best answer is to have the LPN/VN collect intial data on the client and report it to the RN. The RN can evaluate data and initiate the priorities of care. Assessment on the new client should be completed by an RN within eight hours of arriving on the unit. It is acceptable to let the LPN/VN initiate the process. It would be best if a licensed person did a brief initial assessment on the child instead of the UAP. 1. Incorrect: Initial assessment is priority and must be done by RNs or a licensed person assigned by the charge nurse. The charge nurse is accountable for the initial assessment and must take the data and evaluate it and set the plan of care. 2. Incorrect: The RN can assign this takes but is accountable to verify the information and sign off on the data. The RN cannot delegate the assessment process but can obtain data collection assistance from the LPN/VN. 4. Incorrect: Initial assessment is priority and must be done first. The charge nurse cannot ignore a newly admitted client. Anew admission is always considered unstable and requires an initial observation and data collection by a licensed personnel. As soon as information is collected, the RN must evaluate it and set the priority to obtain the entire nursing history and initial plan of care.)

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Invite staff to contribute ideas on scheduling changes. (3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. One important aspect is encouraging the flow of ideas between management and staff members. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. When staff do not feel vested in any new process, there is a sense of underappreciation. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 2. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already pre-determined. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Assigning blame for the changes to administration will not help staff adjust.)

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing? 1. Draining the colostomy bag on a client with diarrhea. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

3. Placing the traction weights on the bed to transfer the client to x-ray. (3. Correct: Traction should never be relieved without a primary healthcare provider's prescription. It can result in muscle spasm and tissue damage. This client could be transferred with traction still maintained. 1. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 2. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Each ROM movement should be repeated 5 times during the session. 4. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. The nurse would then start the 24 hour urine once the 1st void has been discarded. The nurse also needs to be aware of the color and amount of urine voided.)

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? Select all that apply 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3. Report what was seen to the supervisor. 5. Follow procedure to return medication to the resident's supply. (3. & 5. Correct: The nurse should follow the procedure to return the narcotic, and then the nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired. 1. Incorrect: This may be the first observation; however, it is unlikely that it is the first incidence. The impaired nurse must be reported. You are responsible to the clients on the unit, not to the staff member. 2. Incorrect: The supervisor is the one to provide information on obtaining help. The hospital or long term care facility will have a policy for the supervisor to follow. Usually this policy also includes rehabilitation. 4. Incorrect: The nurse should leave if she is taking narcotics. The supervisor will be the one to send the nurse home. The supervisor needs to determine if the degree of impairment would interfere with the ability to drive home safely.)

The licensed practical nurse (LPN) is assisting with care for a client who has an absolute neutrophil count of 500. Which action by the LPN would warrant intervention by the RN? 1. Using an alcohol-based hand rub for hygiene before and after glove removal. 2. Advising visitor with known respiratory infection to not enter the client's room. 3. Taking fresh flowers into the client's room that were delivered by the local florist. 4. Leaving the thermometer and sphygmomanometer in the client's room.

3. Taking fresh flowers into the client's room that were delivered by the local florist. (3. Correct: First of all, did you recognize that the absolute neutrophil count (ANC) was very low? So what does this mean for this client? The neutrophils are an important component of the blood that is responsible for fighting infections. A client with a low neutrophil count is considered to be neutropenic and precautions for preventing infections are needed to protect the client. Carrying the fresh flowers into the room that were delivered by a florist may seem like a harmless gesture. But, it is not! Plants and flowers can harbor fungal spores that can be harmful to clients who are immunosuppressed. Therefore, the RN should intervene and not allow the fresh flowers to be taken into this client's room. 1. Incorrect: Using an alcohol-based hand rub for hygiene is the preferred method for decontaminating the hands, unless the hands are visibly soiled. This should be used before and after glove removal. Therefore, the LPN would be using an acceptable practice and the RN would not need to intervene. 2. Incorrect: Since the client has a low neutrophil count and is at risk for infections, the nurse should institute measures to protect the client. This would include advising any visitor with a known respiratory infection to not enter the client's room. The LPN would be protecting the client, and this would not require intervention by the RN. 4. Incorrect: The room for a client with neutropenia should have its own equipment that is not taken out and shared with other clients. This includes such things as thermometers and sphygmomanometers. This equipment should be properly disinfected prior to being brought into the client's room and is not shared with other clients to reduce the risk of contamination to the immunosuppressed client. The LPN would be performing safe nursing care and would not require intervention by the RN.)

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.

3. The RN with 5 years' experience in the Labor and Delivery unit. (3. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client needs careful monitoring and specialized care. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. 1. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. Therefore, this would not be the most appropriate nurse to assign to this client. 4. Incorrect: Although this nurse is working on the postpartum unit, they do not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client.)

In which situation should the nurse consult the client's advanced directive? Select all that apply 1. Client scheduled for breast reconstruction after mastectomy. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.

4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused. (4., & 5. Correct: 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 Advanced Directive. Both of these clients are terminal. 1. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. The option does not say the client is terminal, in a vegetative state, or in a coma. 2. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions 3. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity.)

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

4. Discuss suspicions with unit nurse manager. (4. Correct:The greatest concern at this time is the safety of the clients to whom the intoxicated nurse is providing care. The nurses Code of Ethics dictates safe, effective care for the public with protection from incompetent or unethical practice. The chain of command for this floor nurse is to report directly to the unit nurse manager. 1. Incorrect: When dealing with ethical or legal issues, the chain of command starts with the nurse manager of the unit in question. Asking another staff nurse for a personal opinion would not provide any pertinent data and instead amounts to gossip. 2. Incorrect: In order to avoid undue conflict, the nurse needs to immediately alert the unit nurse manager and not the facility supervisor. The nurse manager must then manage any conflict that may result and bears the responsibility to control possible disruption resulting from re-assigning the impaired nurse's clients. 3. Incorrect: Direct confrontation of the allegedly impaired nurse would most likely result in denial or defensive behaviors which could place the clients at further risk. The chain of command for this staff nurse starts with the unit nurse manager who would be more qualified to deal with conflict resolution in this matter.)

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Give the report to the hospital's risk management team. (4. Corect: The purpose of an incident report is to describe and document a particular event, injury, medication error, or other occurrence that affects a client or staff member. This report is then sent directly to the hospital risk management team for the express purpose of developing a plan or protocols to prevent a repeat occurrence. 1. Incorrect: Although the primary healthcare provider will need to be informed of the medication error and the client's current status, including vital signs, a copy of the incident report is not provided. 2. Incorrect: The State Board of Nursing is rarely notified about medication errors or the existence of an incident report. 3. Incorrect: The information documented on the main chart includes the client's current status and assessment specifics. It should also be documented that the primary healthcare provider was notified. However, there should not be any mention of the incident report on the client's chart.)

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

4. Have staff visit client's room every 15 minutes. (4. Correct: It is vital for clients to be able to contact or alert staff for needs and concerns. The safest method is for the staff to check on the client at specified intervals. This will help alleviate client concerns about being able to signal the staff while ensuring that someone actually observes the client. 1. Incorrect: While a hand-held bell could be an option, it is not reliable. The client could easily push it onto the floor, or it could become tangled in the linens. Additionally, depending on the noise level of the unit, a hand bell could either disturb other clients or not be heard by staff. 2. Incorect: It is not the responsibility of the family to sit with the client 24/7 just because the hospital has non-working equipment. Not only would this be an imposition, it violates most visiting policies and places the burden on the family. 3. Incorrect: Having a client call out to staff is both inefficient and unsafe. Assuming the client's voice is even loud enough to be heard, it is unlikely that the verbalizations of one client could be distinguished from others that may call out because of dementia or normal nighttime utterances. This is not safe.)

The nurse is monitoring care provided to clients by a newly hired unlicensed assistive personnel (UAP). Which action by the UAP would require the nurse to intervene? 1. Uses a gait belt when ambulating a client with right sided weakness. 2. Repositions a client in bed using a lift sheet. 3. Disconnects nasogastric (NG) tube from suction to allow ambulation to toilet. 4. Massages a surgical client's calf after reports of leg cramping.

4. Massages a surgical client's calf after reports of leg cramping. (4. Correct: The UAP could dislodge a blood clot in the leg when massaging the calf. The nurse should intervene on behalf of the client. 1. Incorrect: Placing a gait belt prior to ambulating a client is an appropriate action for safety and would not require intervention by the nurse. 2. Incorrect: Using a lift sheet will help prevent injury to the client. The lift sheet decreases shearing that can occur when pulling a client up in the bed. It also allows for positioning without holding onto parts of the client's body, which could result in injury. 3. Incorrect: Disconnecting the NG tube from suction is an appropriate task for the UAP. Suction should be reconnected by the nurse, so that correct pressure is checked.)

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Notify primary healthcare provider immediately. (4. Correct: The nurse must notify the primary healthcare provider immediately about the client's desire to leave without care. The client cannot be physically prevented from leaving, or threatened with possible dire consequences by the nurse. The primary healthcare provider can explain potential risks of non-treatment and obtain a signature on the AMA form. 1. Incorrect: The client must be informed about the potential risks of leaving without medical treatment and that information is best explained by either the emergency room healthcare provider or primary healthcare provider based on knowledge of the client's potential injuries. 2. Incorrect: An "Against Medical Advise" (AMA) form is designed to protect staff and facility from potential litigation filed by clients leaving without treatment. However, a client cannot be forced to sign the form and this is not the nurse's priority action. 3. Incorrect: The nurse can use therapeutic techniques to discuss the situation and try to discover why the client wants to leave. However, there is another priority more important for the nurse.)

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I&O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy. 3. Ambulating a client who is 2 days post vaginal hysterectomy. 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on.

4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. (4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.)

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO₂ 88, PaCO₂ 44, and HCO₃⁻ 22. Client two days post thyroidectomy who has a negative Trousseau's sign. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24.

Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO₂ 88, PaCO₂ 44, and HCO₃⁻ 22. Client two days post thyroidectomy who has a negative Trousseau's sign. (All these clients have an endocrine problem. So, now you must decide in what order to assess each of these clients. The first client the nurse needs to assess is the client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Do you see shock (Addisonian Crisis)? You should. This BP is too low. You don't even have to know anything about Addison's disease to know this client is critical and could die if intervention is not rapid. The second client the nurse needs to see is the client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. The client's airway is stable since the client is intubated, however, the nurse needs to monitor this client frequently to ensure the airway remains patent. The third client that should be assessed by the nurse is the client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO₂ 88, PaCO₂ 44, and HCO₃⁻ 22. Look at these blood gases. Normal. What is iatrogenic? Caused by medical treatment: symptoms, ailments, or disorders induced by drugs or surgery. Most likely this client developed Cushing's due to steroid administration for the cancer. The fourth client the nurse should assess is the client two days post thyroidectomy who has a negative Trousseau's sign. A negative Trousseau's is a good thing. This client is stable two days postop.)

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. Female client stating she has been raped. Client who has multiple injuries from a motor vehicle accident. Client reporting epigastric pain and nausea after eating. Elderly client who fell and fractured the left femoral neck.

Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Female client stating she has been raped. Client reporting epigastric pain and nausea after eating. (The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Injuries from a motor-vehicle accident can be life threatening. The client should be assessed first to rule out respiratory difficulty and hemorrhage. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. Elderly clients have special fluid and electrolyte issues after a fall. The cause of the fall may be cardiac, but the question does not indicate this. The third client that should be sent back for treatment is the female client stating she has been raped. We do not know the extent of her injuries based on what the option tells us. There will likely be both physical and emotional injury that needs attention, which places this client third. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. This is likely cholelithiasis, which will need to be checked out. This is the most stable of the four clients which places this client last to be seen.)

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.

1. Allow staff on the unit a voice in the plan for change. (1. Correct: Allowing everyone an opportunity to speak may reveal the reasons behind the resistance. If everyone has a voice, each person is more likely to buy into the new method. 2. Incorrect: Supporters and resisters should communicate. Perhaps the supporters can persuade the resisters. Encouraging discussion keeps communication lines open and is more likely to decrease resistance. 3. Incorrect: Setting a date for implementation should come after discussion and training on the new process. A target date must be set; however, the groundwork for change must occur first. 4. Incorrect: Staff is more likely to accept change that affects them if they have a voice. Administration can take staff suggestions and possibly make a better plan.)

Which task would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

1. Changing a colostomy bag. (1. Correct: The only procedure listed that is within the LPN/VN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/VN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/VN. Therefore, the RN must perform this task and cannot delegate this to the LPN/VN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/VN. Teaching can be reinforced by the LPNVN, but they cannot perform the initial teaching. Teaching insulin self administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/VN. This should not be delegated to the LPN/VN.)

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

1. Clean and restock exam rooms after client discharge. (4. Correct: Clients seen in the emergency room are often taken to other hospital departments for tests such as X-rays, Cat scans or MRI's. If ordered to another department for testing, such clients are generally stable and could therefore be transported by unlicensed assistive personnel. This is a task UAP's often do on other hospital floors and would be an appropriate assignment. 1. Incorrect: Having never worked the emergency department before, this UAP would not be aware of even basic exam room requirements, particularly involving specialized equipment. Because supplies must be readily available in critical situations, personnel familiar with those requirements and provisions needed for each room should complete restocking of the rooms. 2. Incorrect: A thorough orientation for this UAP would be ideal, especially if there is a chance of being floated to the emergency room again. However, doing so during a staffing crisis is neither appropriate nor efficient, since the UAP is being utilized out of a desperate need for adequate staffing. 3. Incorrect: The reception area personnel are the first staff that encounter incoming clients. This position usually requires some type of training with interviewing techniques or how to determine an acute situation requiring immediate triage. Even answering the phone would involve understanding the necessary prerequisites for that position. This is not an appropriate task for the UAP.)

After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.

1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. (1. Correct: The client diagnosed with an ischemic stroke needs to be assessed first to be evaluated for signs of increased intracranial pressure (ICP). A neurological assessment should be initiated. Increased restlessness is an early sign of increased ICP. 2. Incorrect: Client safety should be evaluated. The client does require assistance with ambulating. But the client with potential increased ICP requires an immediate neurological assessment. 3. Incorrect: A client with a halo traction may require assistance to transfer to the chair. The nurse identifies that a neurological assessment on another client has priority. 4. Incorrect: The client with the traumatic head injury cannot recall portions of the accident, but is not presenting with any life-threatening symptoms.)

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? Select all that apply 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family (1. & 2. Correct: The LPN can insert a indwelling urinary catheter since hourly urinary output measurements are needed, this is within the scope of practice. The LPN can reinforce an already prepared teaching plan, but cannot develop one. 3. Incorrect: This can best be accomplished by the UAP, it can be done by LPN but not best use of resources. 4. Incorrect: Assessment is a role of the RN. LPN can observe and data collect but not assess and evaluate on the NCLEX. 5. Incorrect: Weighing a client is a task that may be assigned to the UAP.)

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? 1. Involve the client in their plan of care. 2. Delegate 2 nurses to work with the client. 3. Accept the client's behavior as confrontational. 4. Encourage the client to be more cooperative.

1. Involve the client in their plan of care. (1. Correct: The client has the right to be involved in the decision making of their care. The healthcare team should recognize the client as the center of the team. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. 2. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. This action is a defensive intervention, and does not address the quarrelsome behavior. 3. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. 4. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns.)

An experienced RN and LPN are working with a new nurse who has just recently passed NCLEX®. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

1. Lack of experience of the new nurse. (1. Correct: The lack of experience of one of the team members (the new RN) must be considered when delegating for client safety. The new nurse may not have the knowledge, assessment skills, and experience needed to care for clients who are unstable or have complex health issues. 2. Incorrect: Preferences by nurses should not guide delegation decisions. This takes the focus off what is best for the clients and places the focus on the nurse. 3. Incorrect: The possibility for conflict when delegation decisions are made should not influence these decisions which are made in the best interest of the client. 4. Incorrect: Although it seems like the "fair" thing to do by each nurse caring for the same number of clients, the delegation decisions should be based on the experience of the new RN. Client safety could be compromised by assigning the new nurse to clients who are unstable or have complex health issues. Delegation to the LPN must include consideration of the LPN's scope of practice.)

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Select all that apply 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale. (1., 2., 4., 5. Correct: If nurses have been provided the knowledge and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. Of course, nurses must have read the standards and understand them. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. Perhaps a process is not working properly. So assessment is first. 3. Incorrect. This is not the most effective way of improving performance as it is considered punitive. If the above listed strategies are not effective, formal reporting of the behavior may be necessary.)

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.

1. Soaking the dentures in hot water 4. Wrapping the dentures in tissue while the client sleeps (1. & 4. Correct: Hot water may damage dentures so intervention is needed. Dentures should be stored in a denture cup. 2. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 3. Incorrect: Moistening the dentures will ease insertion. 5. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped.)

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

1. Tell the UAP to keep the client covered at all times. (1. Correct: A comment should be made about keeping the client covered. This instruction is the first action after covering the client. 2. Incorrect: The nurse should talk with the UAP but the discussion should focus specifically about providing privacy for clients. 3. Incorrect: The nurse may want to provide teaching, but this is not first action. Teaching would require allowing enough time to give instructions and then arranging time for return demonstration. 4. Incorrect: The UAP should be allowed to finish the bath. Additional assistance is not needed.)

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, wwhen they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. (1. Correct: The experienced nurse demonstrates an understanding of appropriate staff supervision by answering that the charge nurses are accountable for supervising client care and safety after they have made client care assignments, and by clarifying that the charge nurses are probably attempting to be supportive of the new graduate nurse. 2. Incorrect: This answer does not address the nurse's question correctly. This answer is an example of nontherapeutic communication. The nurse is giving the opinion that the charge nurse's supervision technique is annoying. 3. Incorrect: The nurse is making a statement about the charge nurse's intentions, but does not know what the nurse's intentions are. The role of the charge nurse should be addressed. 4. Incorrect: This is a negative statement about the nurse's job performance. A more positive approach is to explain the charge nurse's role.)

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

2. Case manager (2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan. 1. Incorrect: The primary healthcare provider does not assume the case management role in the acute care facility setting, and generally does not coordinate the discharge planning process. 3. Incorrect: The physical therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility. 4. Incorrect: The occupational therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility.)

A nurse, who has been assigned to the Emergency Response Team, is beginning to work on the agency's disaster response plan. What would be the nurse's role in this disaster response plan? Select all that apply 1. Perform duties specific to the area of expertise only. 2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources.

2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources. (2., 3., 4., & 5 Correct: The role of the nurse in disasters can vary greatly. However, it is imperative that there is clarity regarding the individual (nurse, primary healthcare provider, etc.) that will be in charge of a particular client care area and what activities each nurse may or may not perform. Disasters can bring unique security issues. Nurses should be acutely aware of these and plan for ways to manage identified issues. Ethical conflicts in a disaster can involve a discrepancy between client/victim needs and the available resources. Nurses have to be prepared to make decisions regarding resource management. Other ethical issues that nurses may face involve issues such as confidentiality, consents, end of life care, ineffective therapy, requests for assisted suicide, and needing to meet the needs of many more victims than physical resources allow. There are so many responses that nurses may encounter from clients involved in a disaster. Anxiety levels may be high, clients may demonstrate depression, and a strong emotional impact can be experienced. Many various behavioral issues are often noted. Nurses play a vital role in meeting behavioral needs by providing active listening and emotional support. The behavioral and emotional needs may be greater than the nurse can handle on a short term basis. Therefore, it is important for the nurse to know when to refer clients or families to available mental health resources. 1. Incorrect: Nurses can take on many different roles during a disaster. Nurses should realize that they may be asked to "step out of their comfort zone" and not only perform duties that are outside of their area of expertise, but also may be expected to take on some responsibilities that are typically carried out by primary healthcare providers and advanced practice nurses.)

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Provide positive feedback to the UAP. (2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. This individual should be provided appropriate comments of appreciation for this accomplishment. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. It would not be appropriate to overload this new employee with extra work. 3. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. The nurse cannot allow the UAP to perform advanced tasks.)

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

2. Speak to the UAP to determine what happened with the feeding. (2. Correct: Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served. The key word in the stem is first. The other options may be correct but are not the best first action. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. The reason for the UAP not feeding the client needs to be determined. 3. Incorrect: The nurse retains the responsibility for the delegated task. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. 4. Incorrect: The concern here is the client being fed their meal. Speak to the UAP first and then decide if a between meal supplement is needed.)

A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."

3. "Thickened liquids are safer for the client to swallow." (3. Correct: Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration. The client should be sitting upright and fed small amounts of food slowly, allowing time for chewing and swallowing. This statement indicates the UAP understands proper feeding protocols. 1. Incorrect: Semi-fowlers is a "semi-reclining" position, which would greatly increase the risk of aspiration during meals. This comment indicates the UAP would need further instruction. 2. Incorrect: It is crucial to encourage a stroke client to participate as much as possible in self-care, including feeding and bathing. If this client is capable of using utensils, such as modified silverware, it is important to allow as much participation in activities of daily living (ADL) as possible. If the UAP made this comment, further teaching is indicated. 4. Incorrect: Liquids after every bite would quickly fill up the client, decreasing the amount of food intake. Feeding slowly and allowing the client time to swallow after each bite is sufficient for digestion. Such a statement from the UAP means further instruction is needed.)

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm³ in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm³ in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

3. Absolute neutrophil count of 400/mm³ in a child with fever. (3. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. This client is at a high risk of infection. We see that the temperature is already elevated, which makes us worry that infection is present. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 1. Incorrect: Although the potassium level of 3.4 mEq/L (3.4 mmol/L) is slightly decreased, this level can be corrected and should improve when the vomiting and diarrhea subside. The nurse should continue to monitor the potassium level, but it does not take priority over the extremely low ANC in the child with fever. 2. Incorrect: This platelet level of 95,000/mm³ is below the normal range of 150,000/mm³ to 400,000/mm³. When the level gets below 100,000/mm³, the clients should be monitored for bleeding such as a nose bleed, which this client has. However, nose bleeds are not that uncommon and can often be controlled by applying pressure to the nares for 5 to 10 minutes. We would not expect to see severe hemorrhage until the levels are much lower, so this client would not be a priority over the client with the low ANC with fever. 4. Incorrect: This hemoglobin level of 9 g/dL (90 g/L) in a child who has reported fatigue is below the normal of 11-15 g/dL (110-150 g/L). However, the fatigue can be managed by regulating the activity to conserve oxygen expenditure and prevent fatigue. The child with the low absolute neutrophil count with signs of an advancing infection would take priority over this child with a slightly low hemoglobin.)

A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse considers various ideas submitted by team members. What proposal would the nurse determine to best meet the needs of families and clients in long term care? 1. Plan all care to be completed in early morning to allow afternoon for visitation. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. 3. Encourage clients and families to develop mutually appropriate visitation times. 4. Allow families unlimited visitation around the clock to meet their schedules.

3. Encourage clients and families to develop mutually appropriate visitation times. (3. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 1. Incorrect: This is not completely practical for everyone. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. This schedule may leave some clients too exhausted to visit with family. 2. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. A two-hour limit on visits discourages quality time. 4. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility.)

The nurse is explaining HIPAA regulations to a new client admitted for the first time. What statement by the nurse is most accurate regarding client's personal health information? 1. Cannot be released to other organizations without client consent. 2. May never be used for research purposes or disease tracking. 3. Permission is implied if client has family in room during exam. 4. Will not be publically released without direct client consent.

3. Permission is implied if client has family in room during exam. (3. Correct: When a client is being examined or discussing health information with the primary healthcare provider, and allows family in the room during that time, permission is then assumed. In such circumstances, under HIPAA regulations, it can be "reasonably inferred" that the client does not object to those individuals having knowledge about current healthcare information. 1. Incorrect: If the client is an organ donor and is determined to be legally brain dead, such information can be released to those organizations responsible for organ procurement, including groups which harvest or transport the organs. Also, certain circumstances require mandatory reporting to specific organizations such as gunshot wounds or diseases posing a threat to the public. 2. Incorrect: Certain information can be released for research or disease tracking with special permission, or may be released without consent in cases of public health threats, such as new epidemics or highly contagious disease processes. However, even in research situations, personal identifying information is not provided, such as names, addresses or social security numbers. 4. Incorrect: Information can be publicly disclosed if there is evidence of serious threat to public health and safety, even if the client is unable to verbally consent. An example might be if a client is unconscious, or returns from traveling with a rare, fatal disorder which is airborne or transmitted by droplet.)

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

3. Prepare a sitz bath for a postpartum client. (3. Correct: The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 1. Incorrect: This is not within the scope of practice for the UAP. The nurse must assess and evaluate.Checking the bladder for distension is an assessment that requires the nurse's attention. 2. Incorrect: This client is not stable if having episodes of syncope that could be related to orthostatic hypotension. Since the client is not stable, the UAP should not obtain the client's BP. The nurse should assess the client. 4. Incorrect: The nurse cannot delegate an assessment or evaluation task to the UAP. This is beyond the scope of practice for the UAP.)

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

3. Reminding the client to avoid cold foods and smoking. (3. Correct: Reminding clients to follow through on teaching performed by the RN such as to avoid cold foods and smoking would be an appropriate task for the UAP. 1. Incorrect: Sharing successful anxiety reduction measures is teaching. This is the role of the RN and would not be appropriate to delegate to the UAP. 2. Incorrect: Although encouraging a client to express concerns about the possibility of having an ileostomy sounds like something that could be assigned to the UAP, this would require assessment of the client's concerns and should be performed by the RN. 4. Incorrect: Explaining the rationale for needing a low residue diet is teaching. This is outside the scope of practice for the UAP. The RN should retain all tasks related to teaching.)

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Thoracentesis reporting shortness of breath. (3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.)

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

4. Ask the nurse the reason for being tardy. (4. Correct: The first action should be discussing the tardiness with the nurse. There may be a situation that is impacting the nurse's ability to be on time. This will allow the nurse to explain the tardiness. The nurse manager may have to consider alternate scheduling for the nurse. 1. Incorrect: The first action should not be confrontational. The nurse manager needs to find out the reason for tardiness in a non-confrontational manner. This will demonstrate that the nurse manager is showing concern for the nurse. 2. Incorrect: The nurse is not exhibiting any impairment behaviors. Although drug use may be characterized by behaviors such as tardiness to work, this should not automatically be assumed. The nurse should have the opportunity to first provide an explanation for the tardiness. 3. Incorrect: Documentation should be done after the meeting with the nurse. The documentation would include the nurse's explanation for the tardiness.)

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? Client to receive dietary education. Client reporting a headache and has a fruity breath. Client eating a simple-carb snack due to weakness. Client scheduled for a dressing change to foot ulcer.

Client reporting a headache and has a fruity breath. Client eating a simple-carb snack due to weakness. Client scheduled for a dressing change to foot ulcer. Client to receive dietary education. (The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.)

In what order should the nurse assess assigned clients following shift report? What would be the priority order? Client with emphysema who has a pulse oximetry reading of 89%. Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. Client two hour post lobectomy. Client on ventilator needing a nasogastric tube feeding. Newly admitted client diagnosed with esophageal cancer.

Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. Client two hour post lobectomy. Newly admitted client diagnosed with esophageal cancer. Client on ventilator needing a nasogastric tube feeding. Client with emphysema who has a pulse oximetry reading of 89%.

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement.

Elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. (All these clients have a GI problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This is an elderly client who is a new admit. The client reports constipation for 4 days which may be an indication of worse problems. The client is considered unstable until assessed by the nurse. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Did you think dehydration and fluid volume deficit? The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This is normal for clients with hemorrhoids. But the client does need to be assessed prior to the client with Crohn's disease who is improving. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Semi-formed stools are great news! The client is getting better. During exacerbation, the client will have many diarrhea stools.)

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. Alert the Unit Manager. Complete an incident report. Report what happened to the health care provider. Obtain the client's vitals.

Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report. (The first priority in such a situation is to check the client for any immediate problems secondary to receiving the incorrect medication and obtain a set of vitals. The client status is always your priority. Second, the nurse should notify the Health Care Provider of what happened, and implement any counter measures that may be ordered. Third, the Unit manager must be informed of this occurrence, allowing for a review of medication administration protocols and policies. This person is contacted after the client is stable. Take care of the client first. Fourth, the nurse will complete an incident report, per the facility's protocol, to assist in the identification and correction of any safety issues regarding the administration of medications.)

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

1. Client scheduled for an MRI of the kidneys. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness. (1., 3., & 5. Correct: There is nothing in the option regarding the client going for an MRI of the kidneys that would indicate that this client is unstable. This client can be assigned to the LPN. The one day postop client with a moderate amount of serous drainage on the dressing is stable. Skills required to care for this client are within the LPN's scope of practice. The client diagnosed with osteoarthritis reporting frequent joint stiffness can be considered stable and can be cared for by the LPN. The knowledge and skills required to care for these three clients fall within the scope of practice for the LPN. 2. Incorrect: Administration of antineoplastic medications require the skills and knowledge of a qualified registered nurse. 4. Incorrect: An ileal conduit is a procedure that diverts urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL per hour. This client should be assessed and monitored by the RN to ensure that the stents placed in the ureters have not become dislodged or to ensure that edema of the ureters is not occurring.)

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. (1. Correct: This group of clients is primarily med surgical. 2. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This group of clients needs specialized care. 4. Incorrect: No, the monitoring is too specific for the med-surg nurse.)

The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? Select all that apply 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus

1. Financial abuse of an elder 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus (1., 4., 5., & 6. Correct: Federal and state laws require that certain individuals, particularly those who work in health care with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. This includes physical, mental, and financial abuse. Gunshots and knife injuries are reportable to law enforcement. Certain communicable diseases such as gonorrhea and West Nile virus are reportable to the CDC. 2. Incorrect: Suspected negligence of a colleague is not in the realm of mandatory reporting to authorities, but the nurse should discuss with the supervisor. 3. Incorrect: A spouse is not considered a vulnerable person so it is not required by law to report. You should encourage the spouse to report the abuse but you, as the nurse, are not bound by law to do so.)

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? Select all that apply 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. (1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message. The sender is the person who delivers the message, and the receiver is the person who receives the message. 4. Incorrect: The sender and receiver may not share the same life experiences; however, therapeutic communication can still be achieved. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly. However, this is not required for effective verbal communication. 5. Incorrect: There should be congruence between verbal and nonverbal communication. Incongruency can lead to misunderstanding and miscommunication.)

Which assignment would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Totaling I&O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

1. Totaling I&O records on five clients at the end of the shift. (1. Correct: Totaling I & O is an appropriate task for a UAP to be assigned. This is within the scope of practice for the UAP. 2. Incorrect: New clients should be assessed by an RN; however, it is acceptable for the RN to get assistance with some of the information. The RN must verify all information. The client is a new admit, and is considered unstable; therefore, the RN should get the baseline vitals. 3. Incorrect: Administering a NG tube feeding is not within scope of practice for the UAP. 4. Incorrect: Changing a surgical dressing is not within the scope of practice for the UAP.)

Which nursing action would be appropriate to assign to the LPN working at an HIV/AIDS hospice setting? 1. Assessing for signs of secondary opportunistic infections. 2. Collecting data regarding response to pain medications. 3. Teaching the UAP about nutritional needs of HIV/AIDS clients. 4. Assisting clients with personal hygiene needs.

2. Collecting data regarding response to pain medications. (2. Correct: Data collection regarding response to pain medication is within the scope of practice of the LPN. 1. Incorrect: The nursing process, including assessment, requires a higher level skill set and should be carried out by the RN. 3. Incorrect: The development of a teaching plan and teaching are also aspects within the role of RN and should not be delegated or assigned to the LPN. The LPN, however, can reinforce teaching as needed. 4. Incorrect: Activities such as assisting clients with personal hygiene needs can be carried out by a lower level staff (UAP) and therefore, should not be delegated to the LPN.)

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate? Select all that apply 1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the RN to administer the prescribed dose of labetalol hydrochloride IV. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition.

2. Have the LPN reinforce the use of relaxation techniques. 4. Instruct the RN to administer the prescribed dose of labetalol hydrochloride IV. (2., & 4. Correct: The LPN can reinforce teaching. The client's BP is elevated and using relaxation techniques along with the medication that is being administered may help to decrease the client's BP. Labetalol is beneficial in this situation because of its rapid onset of action (approximately 5 minutes). The charge nurse delegates this to the RN because it would be outside the scope of practice of the LPN and not in the role of the UAP to administer IV medication. 1. Incorrect: The LPN cannot assess, evaluate or teach. These are the roles of the RN and are outside the scope of practice of the LPN. 3. Incorrect: Drawing ABGs from an artery is out of the scope of practice of the LPN. 5. Incorrect. It is not in the role of the UAP to notify the primary healthcare provider of changes in the client's condition. The UAP could not receive additional prescriptions should the primary healthcare provider desire to add or change prescriptions based on the client's change in condition.)

A 68 year old client was admitted two days ago to a long term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/min by nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? Prescriptions: Sputum for culture and sensitivity Incentive spirometry every 2 hours while awake Monitor SaO₂ every 4 hours Levofloxacin 250 mg by mouth every 8 hours 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

2. LPN/LVN (2. Correct: All the nursing responsibilities associated with the primary healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. The UAP cannot carry out all of the prescriptions. The charge nurse should not delegate to the RN those things that the LPN can do. So the best person to delegate these responsibilities to is the LPN. 1. Incorrect: Giving medications is out of the scope of practice of the UAP, but can be carried out by the LPN. 3. Incorrect: All the nursing responsibilities associated with the primary healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. Therefore, the responsibilities can be delegated to the LPN and free the RN to do other tasks that are outside the scope of practice for the LPN. 4. Incorrect: The charge nurse is responsible for all client care during the shift, so carrying out these prescriptions is not the best use of time and resources available to the charge nurse since the LPN can perform these things within the scope of practice.)

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? Select all that apply 1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor.

2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. (2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principles of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan, not multiple plans, should be developed. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. There is no feasible way for the hospital to have a response plan for every potential disaster. 5. Incorrect: All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital.)

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Assign a nurse on the floor to initiate the assessment process. (3. Correct: The nurse is the only one who can assess. 1. Incorrect: The UAP can empty the urinary catheter bag, but can not assess the client. 2. Incorrect: It is out of the scope of practice for a UAP to complete any portion of the admission assessment. 4. Incorrect: The unit secretary can welcome the client, but the admission assessment must be completed by an RN.)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. (3. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 1. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 2. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. It is not a routine task. 4. Incorrect: The nurse cannot assign teaching to the UAP.)

During a disaster, four clients arrive at the emergency department (ED). Which client should the nurse assess first? 1. Confused client wondering around ED. 2. Client with a compound fracture. 3. Client having agonal respirations. 4. Client with sucking chest wound.

4. Client with sucking chest wound. (4. Correct: The client with a sucking chest can recover if given immediate attention. 1. Incorrect: This client may have a head injury, however, the client with a sucking chest wound is critical but can survive with immediate care. 2. Incorrect: The client with the compound fracture can be given temporary care, then fully treated later. The priority is the client with the sucking chest wound. 3. Incorrect: The client with agonal respirations will not likely survive and should not be among the first to be treated.)

During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary healthcare provider writes the prescription. Which statement best describes this process? 1. Collaboration with the ancillary care providers. 2. Collaboration between the primary healthcare provider and the dietician. 3. Collaboration with the risk management team. 4. Collaboration among members of the multi-disciplinary team.

4. Collaboration among members of the multi-disciplinary team. (4. Correct: The nurse reporting assessment findings, the dietician suggesting a swallow evaluation, and the primary healthcare provider ordering the swallow evaluation are an example of collaboration of care among members of the multi-disciplinary team. 1. Incorrect: Collaboration of care with the ancillary providers is a partial answer, as is collaboration of care between the primary healthcare provider and the dietary department. These healthcare team members all are part of the multi-disciplinary team. 2. Incorrect: Collaboration of care with the ancillary providers is a partial answer as is collaboration of care between the primary healthcare provider and the dietary department. These healthcare team members all are part of the multi-disciplinary team. 3. Incorrect: Risk management is a formal process through which a healthcare facility or provider agency tracks client outcomes to identify potential problems and ensure safe delivery of care.)

What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Inform the client of the need to avoid irritants such as carbonated beverages. 2. Ask client if they are eating small, frequent meals. 3. Monitor for GI upset 30 minutes after meals. 4. Remind the client to avoid tight fitting clothes.

4. Remind the client to avoid tight fitting clothes. (4. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 1. Incorrect: Informing is the same thing as teaching. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 2. Incorrect: The RN is responsible for collecting data. 3. Incorrect: The RN is responsible for assessment and evaluation.)

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%.

Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. (The first client the nurse needs to assess is the one diagnosed with pneumonia who has a pulse oximetry reading of 89%. A pulse oximeter oxygen saturation level of 94-99% is considered normal for most healthy individuals. A level of 92 percent indicates potential hypoxemia, or deficiency in oxygen reaching tissues in the body. Supplementary oxygen should be used if SpO₂ level falls below 90%, which is unacceptable for a prolonged period. The second client that should be assessed by the nurse is the client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Normal arterial oxygen level is 80-100%. Although 85% is within normal range, it is on the low side of normal. The nurse should assess the client for potential respiratory complications. The third client the nurse needs to see is the client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Sputum specimens need to go to the lab in a timely manner. The nurse could assign the UAP to this task. In any case, the nurse should assess this client third. The fourth client the nurse should assess is the client with the clogged feeding tube. Clogged feeding tubes occur with regularity. Delay in feeding a client will not result in permanent damage.)

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? Select all that apply 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR). (1., 2., 4., & 5. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. An adult (18 years or older) can create an advanced directive. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 3. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document.)

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist (1., 2., 3., 4., & 5. Correct: Care coordination is the deliberate organization of and communication about client care activities between two or more members of the healthcare team, including the client. Nursing is involved with the client 24 hours a day. So, the nurse has knowledge of the client that others may not have. The pulmonologist is the specialist who deals with chronic pulmonary issues and will guide medical care with the team. The social worker may be able to assist the client with financial information and any home care arrangements. The pharmacist will be able to discuss medication regimen that the client is receiving and make suggestions regarding other medications or medication interactions. 6. Incorrect: In this case, the occupational therapist is not needed. Occupational therapists help clients with activities of daily living and modifications to the home environments. Nothing in the stem indicates that this service is needed.)

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis. (1., 2., 4., & 5. Correct: The client who has a cast and requires pain medication is a stable and predictable client. This client needs ongoing monitoring which is within the scope of practice for the LPN. The client with chronic emphysema has expected shortness of breath. This client is stable and predictable. The client post PEG placement is stable. The LPN can monitor the wound and provide care to the PEG insertion site. The client with cystitis is stable and has a predictable outcome. It is within the LPNs scope of practice to administer antibiotics. 3. Incorrect: This client does not have a predictable outcome. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. This client will also need a lot of education regarding anti-rejection medications.)

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? Select all that apply 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.

1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. (1., 2., 3., & 4. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. 5. Incorrect: Medications are not transferred with the client to a new facility. A list of current medications is sent to the facility.)

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? Select all that apply 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM (1., 2., & 3. Correct: These are stable clients that can be assigned to the LPN. The LPN can provide medications for pain management. Since the postop client is not requiring frequent assessments and is considered stable at this point, the RN can assign the LPN to care for this client. The client having surgery in the AM is stable and will require predictable preop care the evening prior to surgery, so the LPN can care for this client as well. 4. Incorrect: This client has adrenal insufficiency. It occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones are lacking. This puts the client at risk for fluid volume deficit and shock. This would require higher level knowledge and skills of the RN and should not be delegated to the LPN. 5. Incorrect: The client in diabetic ketoacidosis is not considered a stable client. The administration of IV insulin is outside the scope of practice for the LPN. Caring for this client would require higher level assessment skills, knowledge, and nursing care that is within the RNs scope of practice. This client should not be assigned to the LPN.)

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Meet with the family member and the RN to discuss the disagreement. (1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the nurse manager is not caught in the middle. They will be able to come up with solutions together or the manager can mediate. 2. Incorrect: It is ok to clarify that the nurse followed hospital procedure. However, the nurse is sing the nontherapeutic communication technique of blocking. The family member may still believe that there is another procedure that could have been initiated. 3. Incorrect: You may want to do this as well, but it will not address the conflict. The conflict is that the family member disagrees with the nurse's procedure for dressing change. 4. Incorrect: The nurse manager must try to resolve the conflict between the family member and the nurse first. If the conflict cannot be resolved the nurse manager would notify the person that is next in the chain of command.)

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Share the assessment findings with the interdisciplinary team. (1. Correct: The assessment findings from the home health nurse will allow each person of the team to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin. The interdisciplinary team works together and shares their expertise, knowledge and skills to improve client care. 2. Incorrect: Suggesting a social worker visit may be appropriate; however, this situation would best be served by a discussion with the entire team first. 3. Incorrect: Nursing home placement may be appropriate; however, this is not the first step in collaboration with the team. The team will discuss the home health nurse's concerns and problem solve to provide solutions. 4. Incorrect: Nutrition is a pertinent issue that may need to be addressed; however, the entire team's input is needed at this point. Also the nurse's concern in the safety of the client in a poorly maintained home.)

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Six year old who ingested diluted bleach. (1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicates neglect or abuse by the parents or caregivers. 2. Incorrect: The child in a burned house would be reported only if the story were inconsistent as to how the house caught on fire, or if foul play is suspected. 3. Incorrect: A child fighting at school is inappropriate, but this doesn't mean there is family abuse/neglect at home. 4. Incorrect: A 16 month old who is sick may not take liquids, but the fact that the mother brought the child in means she is attentive and concerned. The nurse would determine why the 16 month old is not drinking liquids then rehydrate the child to prevent dehydration.)

What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? Select all that apply 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.

2. Assist with feeding the client. 5. Maintain the head of the bed at 25 - 30 degrees. (2., & 5. Correct: It is within the scope of practice for an UAP to maintain a designated bed position and assist with feeding a client. The nurse is responsible for setting the bed at the prescribed position and will direct the UAP to maintain this bed position. The UAP is also trained to assist clients with feeding. 1. Incorrect: Assessing the client's gag reflex is not within the scope of an UAP. A nurse would need to be trained in specific techniques to assess the client's gag reflex. 3. Incorrect: It is not within the scope of a UAP to assess the pain level of the client. The nurse must assess the location and intensity of the headache. The nurse cannot delegate assessing a client to a UAP. 4. Incorrect: The client should be encouraged to express their feelings, concerns, and needs, but he UAP is not trained in therapeutic communication and other medical and psychological client needs. Encouraging the client to express their frustrations is not within the UAP's scope of practice.)

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. (2. Correct: The medical nurse can be assigned to this client. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an antiseizure medication. The stem does not indicate any loss of neurological function resulting from the seizure activity. 1. Incorrect: This client is exhibiting early signs of increased intracranial pressure. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. An increased temperature will have a direct effect on the brain's metabolism and function. There is a possibility that a hypothermia blanket may be prescribed. 4. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension.)

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2. Measuring intake and output 5. Performing oral hygiene for an older client (2. & 5. Correct: Measurement of intake and output and oral hygiene for the older client are tasks that the UAP can perform, and these tasks may be delegated. 1. Incorrect: Reporting of lab results should be accomplished by the nurse who has the knowledge to interpret results. This is not appropriate for the UAP and must be done by a licensed nurse. 3. Incorrect: Removal of the IV requires assessment skills that the unlicensed assistive personnel does not have. 4. Incorrect: Discussion of client's condition should be done by the nurse with the client's permission.)

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

2. Research professional articles for guidelines to activities in long-term care. (2. Correct: Research based criteria generally have a high rate of success because the testing has been completed under controlled circumstances and are practice based. 1. Incorrect: Although it would be acceptable to speak with the clients' families, this would not provide the most complete data for the project. Families would not likely understand pertinent considerations such as cost of supplies, number of staff required to assist, or clients' ability to participate. 3. Incorrect: While encouraging client input does allow for some independence, multiple choices can be overwhelming for elderly clients. There would also be an unnecessary expense in purchasing and providing multiple choices for the clients. 4. Incorrect: Most facilities individualize activities based on clientele, funding, and even location. Activities that work in one long term care facilities may not be appropriate for another facility.)

A newly hired nurse from South America is being oriented to a medical-surgical unit. The hospital recently changed to a digital computer system, including laptop stations in client rooms for documentation. The new nurse resists using the system, indicating the process is "too advanced to learn". What is the most appropriate action by the charge nurse? 1. Report the nurse's refusal to the supervisor for disciplinary action. 2. Have the new nurse shadow staff to observe the computer process. 3. Arrange for nurse to receive special training by education department. 4. Assign only personal care to the nurse until able to use the new system.

3. Arrange for nurse to receive special training by education department. (3. Correct: The charge nurse is aware this type of computer system is unfamiliar to the newly hired nurse. In order to utilize all trained personnel to their ability, arranging for special training for the new nurse is the most appropriate action for the charge nurse. 1. Incorrect: Disciplinary action is inappropriate in this situation. Expressed fear of a new computer system by a staff member does not necessitate disciplinary action. This does not address the issue. 2. Incorrect: While shadowing a competent staff member could help the new nurse acquire some computer basics, this process would be too slow. Additionally, shadowing another staff member eliminates a well-trained set of hands from providing care on the unit. 4. Incorrect: A nurse should never be assigned to duties below the scope of practice. This action would decrease the number of qualified nurses providing care on the unit, which could compromise client safety and place the overloaded nurses' license in jeopardy.)

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? 1. Identify a new goal for the client since this one has not been achieved. 2. Consider new nursing interventions for achievement of the goal if the condition still warrants it. 3. Determine that the nursing interventions were performed as planned. 4. Allow more time for achievement of the goal.

3. Determine that the nursing interventions were performed as planned. (3. Correct: First, the nurse will want to determine that the interventions were performed. If they were not carried out, the goal could not be achieved. In addition, the nurse should determine if the nursing interventions were carried out appropriately and completely. Evaluation of the effectiveness of the nursing interventions would follow. 1. Incorrect: New goals may need to be identified; however, in this case it is not yet known if the interventions were carried out appropriately. Until it is determined that the current nursing interventions were implemented and performed appropriately, there is no way to accurately explore if new goals are needed. The original goals may be the most appropriate for the client. 2. Incorrect: New interventions may be appropriate; however, there is another option that is better. The original nursing interventions should have been identified based on the client's needs. Until the nurse determines if these were carried out appropriately, it would be premature to establish new nursing interventions. 4. Incorrect: Additional time for goal attainment may be appropriate; however, other actions should be performed first. Before extending time for achieving the goal, the nurse should determine if the nursing interventions have been carried out appropriately. If these have been performed, extending the time for goal attainment may delay making changes that are needed.)

An adult client's parent, who is a physician, comes to the nurse's station and requests the client's chart. The physician is not the client's primary healthcare provider but is employed by the hospital. What action should the nurse take? 1. Provide the physician with the chart. 2. Ask the primary healthcare provider to consult the physician in the client's care. 3. Explain to the physician why access to the chart cannot be provided. 4. Obtain verbal permission from the client for the physician to view the chart.

3. Explain to the physician why access to the chart cannot be provided. (3. Correct: The nurse must maintain the client's right to confidentiality. The parent, even though a physician, is not the client's primary healthcare provider, thus has no medical need to see the chart. The nurse should not allow the physician access to the chart. 1. Incorrect: The parent (physician) is not the client's primary healthcare provider. Providing access to the chart breaches confidentiality. 2. Incorrect: The nurse should be advocating for the client and should not allow access to the chart without written permission from the client. Circumventing confidentiality by requesting a consult is not the action the nurse should take. 4. Incorrect: Written permission is required from the client, who is an adult.)

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Gather and apply dressings to open wounds. (3. Correct: An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/VN's scope of practice does not include assessment. That task would require an RN or primary healthcare provider. 2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/VN would not be assigned this task. 4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/VN. Additionally, the decision to apply oxygen involves assessment of the respiratory system, which also is not within the LPN/VN's scope of practice.)

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. (3. Correct. Administering the client's blood pressure medicines are aimed at correcting the hypertension. The therapeutic action of furosemide is diuresis which will lower the blood pressure. Enalapril is an angiotensin converting enzyme (ACE) that treats hypertension. These medications can be administered within 30 minutes of 0900. 1. Incorrect. Assisting the client back to bed is appropriate, but does not address the problem of lowering the client's BP. Administration of furosemide and enalapril will benefit the client with hypertension. 2. Incorrect. Retaking the BP in the opposite arm is within the scope of practice of an UAP, but does not address the problem of lowering the client's blood pressure. Additionally this should be completed prior to 15 minutes time. The priority is to get the BP down by giving the prescribed medications for hypertension. 4. Incorrect. The LPN can ask the client if they have chest pain. The client does have a BP of 198/94 which could lead to chest pain. The priority is to get the BP down to decrease the risk of complications associated with hypertension, such as MI, and stroke.

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. "You can refuse to be part of the students' study." (4. Correct: Clients' rights (still referred to in a hospital setting as the" Patient Bill of Rights") is a written code of ethical behavior describing the relationship that exists between the client and any facility to which they are admitted, including mental health units and hospice care. These guidelines provide the client a specified level of expectations regarding, for example, access to care, confidentiality and personal dignity. Regardless of the circumstances of the disease or location of treatment, clients have the right to refuse care from any professional personnel, including medical and nursing students. 1. Incorrect: Implied consent is an inferred agreement in which medical interventions are provided when the client cannot formally agree, as in the case of unconsciousness or incompetence. However, this client is clearly conscious and able to choose whether care by students is acceptable. The fact that the facility is a teaching hospital in no way deprives this client of the right to refuse student involvement. 2. Incorrect: The issue is the client's rights were violated when medical students were allowed involvement in this case without express consent or acknowledgement by the client. This response by the nurse ignores the client's rights or feelings by focusing on student abilities to provide care. It is demeaning to the client and does not address the client's concerns or provide alternatives. 3. Incorrect: Alerting the primary healthcare provider will be one component needed to resolve this situation. However, this initial response by the nurse is inappropriate for two reasons; first, this process transfers care of the client away from the nurse. Secondly, it does not provide the client with specific information about rights or resolutions.)

How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care. (4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care. These clinical pathways reduce the degree of variation in clinical practice, improves outcomes, and promote organized and effective client care based on evidenced based practice. Clinical pathways are different from algorithms, practice guidelines, and protocols because they incorporate a multidisciplinary team approach and focus on coordination and quality of care. 1. Incorrect: A decision-making flowchart that uses the if/then method is the definition of an algorithm. The algorithm direction changes based on the information gained at each level of the algorithm, so decisions for actions will be different. 2. Incorrect: A set of practice guidelines developed by professional medical organizations is the definition of a practice guideline. These guideline assist in decision making about appropriate healthcare for specific clinical situations but are not fixed protocols that are designed to be followed in an exact manner. They are recommendations for consideration. The practice guidelines are specific to practice areas rather than having a multidisciplinary approach. 3. Incorrect: A standardized set of preprinted primary healthcare provider prescriptions. These preprinted prescriptions are available for immediate access and use with clients, include commonly prescribed interventions, and reduces oversight of interventions by having a standardized format. Other advantages have also been identified for the use of preprinted prescriptions.)

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the plan will be implemented and those not following the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments. (1. Correct: The key word in the stem is first. So yes, get everyone together and discuss the problem and find areas of compromise where possible. 2. Incorrect: Too authoritative. This is good staff that has worked together on the unit for a long time. We want them to be happy and get the work done. Again, the key word in the stem is first. 3. Incorrect: No, this is a manager's issue resulting from a new system. This may need to be done but is not the first action. 4. Incorrect: Explaining the rationale to one group does not promote teamwork. It is better to plan a unit staff meeting and not a meeting for only the UAPs.)

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietician talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

4. Provide additional information as requested by the client concerning nourishment. (4. Correct: This client is alert and competent, and has the right to make healthcare decisions and the right to die with dignity. The nurse should provide any additional information as requested by the client. 1. Incorrect: This is inappropriate, as it does not follow the client's wishes and would be a violation of client rights. 2. Incorrect: The client has made the decision to refuse nourishment so this action ignores this decision and violates client rights. 3. Incorrect: The nurse should honor the client's wishes first. The family would only need to meet if the client became unable to make decisions on their own. Even so, these decisions could not violate any advance directives that were in place.)

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. The nurse does not know the skills of the new UAP. (4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot determine this, the task should not be delegated. This determination is needed to assure client safety is being considered. 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 2. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. If the client is unstable, the nurse would retain the role of measuring the vital signs. Once the client is stable, the UAP could perform this task. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client.)

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. Indwelling foley catheter inserted the previous day Laparoscopic exploration of right knee 2 days ago Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago

Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago Laparoscopic exploration of right knee 2 days ago Indwelling foley catheter inserted the previous day (The client with the greatest risk of infection would be the client with thermal burns covering 30% of the BSA. Burns are considered contaminated wounds. Normally, skin provides a natural barrier against invasive microorganisms. However, with this major burn injury, the client is predisposed to infection as a result of the loss of skin integrity. Additional factors that will place this client at higher risk for infection include the development of eschar, which bacteria loves to live in, and the fact that thermal injuries alter the body's natural immunity. The client with the total hip arthroplasty (replacement of the damaged hip with a prosthetic device implanted) would be the next highest in ranking for risk of infection. This client has a relatively large surgical incision and a prosthetic device that infection, when present, tends to migrate to the area. But, this type surgery is performed using sterile technique in sterile environments to minimize the risk of infection. In addition, any dressing changes should be performed using sterile technique. The next client at risk of infection would be the client with the laparoscopic exploration of the right knee. Again, there is surgical perforation of the skin. However, these are smaller puncture sites that are created under sterile conditions, and when cared for appropriately, do not carry a high risk for infection. Finally, the client who has the indwelling foley catheter is the least at risk for infection. The catheter is a portal of entry into the body, but if inserted using sterile technique and proper catheter care is provided, the risk of infection can be kept to a minimum. The longer the foley catheter remains in place, the risk of infection will increase.)

The charge nurse in the pediatric unit is making assignments for the day shift. What clients would be appropriate for an LPN floated from the medical-surgical unit? Select all that apply 1. A 12-year-old with diabetes mellitus. 2. A 6-year-old one day post tonsillectomy. 3. A 3-year-old admitted in sickle cell crisis. 4. A 9-year-old with Hirschsprung's disease. 5. A 2-year-old in a mist tent with epiglottitis.

1. A 12-year-old with diabetes mellitus. 4. A 9-year-old with Hirschsprung's disease. (1 and 4. Correct: The LPN scope of practice is task oriented. An LPN floated to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical-surgical floor. The 12-year old with diabetes mellitus is a good choice. This client will require accu-checks and SubQ insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who would have experience with bowel issues. 2. Incorrect: Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given I.V. since the child still has difficulty swallowing. LPN's may not give I.V. meds. 3. Incorrect: Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. Incorrect: A two year old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.)

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. (1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined.)

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4. Avoids touching edges of the ampule when inserting needle.

1. Snaps the neck of the ampule gently towards the body. (1. Correct: An ampule is a glass vial with a narrow, scored neck that must be snapped off to open. Even if the neck of the ampule is covered with gauze, the proper procedure is to snap the top away from the body, not toward the body. If the new nurse attempts to snap the top of the ampule toward the body, the charge nurse would need to intervene immediately. 2. Incorrect: This is a correct action. When a glass container is broken, there is the potential for tiny glass shards to fall into the solution and subsequently be infused into the client. To avoid this situation, a filter needle must be utilized to draw up the solution from the ampule. Once drawn up, the filter needle is removed and a regular needle utilized to inject the solution into the client. This is a correct action. 3. Incorrect: The use of an alcohol wipe or small gauze sponge, wrapped around the neck of the ampule prior to snapping the top open is crucial to prevent injury to the nurse. Exposure to the jagged glass top could easily cut a thumb or finger while holding the vial. No intervention needed here. 4. Incorrect: The scenario asks for an incorrect action requiring intervention by the charge nurse. However, this action is appropriate. It is always important to avoid touching the edges of the opened ampule when inserting the needle to prevent possible contamination of the solution.)

A client who is sitting in a chair begins to have a tonic-clonic seizure. In what order should the nurse intervene? Position client on side. Ease client to the floor. Push aside any furniture. Administer prescribed antiepileptic medication.

Ease client to the floor. Position client on side. Push aside any furniture. Administer prescribed antiepileptic medication. (When a client has a seizure, the priority is safety. The nurse must protect the client from injury. This client is sitting in a chair when the seizure occurs. So, the first action by the nurse would be to ease the client to the floor. Otherwise, the client could fall. Second, the nurse should position the client onto the side. This will protect the client's airway. With the client on their side, the risk of aspiration is decreased, and the tongue will not become an obstruction. Third, move furniture out of the way. During a seizure, the client's extremities may move around violently striking furniture near. After making certain the client is safe, administer any prescribed antiepileptic medications. This is usually prescribed when a seizure lasts longer than 2 minutes.)

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. Adult reporting right lower quadrant abdominal pain. Teenager with a blood glucose of 108 mg/dL (6 mmol/L). Child who has a laceration to the hand with bleeding controlled by pressure. Infant having a tonic-clonic seizure.

Infant having a tonic-clonic seizure. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. Adult reporting right lower quadrant abdominal pain. Child who has a laceration to the hand with bleeding controlled by pressure. Teenager with a blood glucose of 108 mg/dL (6 mmol/L). (First the nurse needs to evaluate the infant having a seizure. This client is in acute distress. The infant should be treated first to assess the infant's airway and neurological status. Second would be the elderly client presenting with chest pain who has a pain intensity of 4 on a scale of 10. Chest pain is possible symptom of a lethal cardiac event. At the time of the triage the infant's seizure activity and potential airway obstruction should be attended to first. Third would be the adult client with abdominal pain. The abdomen is painful, but clients with potential life-threatening complications should be evaluated first. Next, the child presenting with a laceration to the hand, should be seen. The bleeding is under control with pressure so can be seen after the other three clients. The teenage client's blood glucose level is with normal limits. The other clients should be attended to first, so this client would be last.)

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholics Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

1. Alcoholics Anonymous (1. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This referral would be appropriate. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Aplastic anemia is a rare but serious condition. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated.)

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1. Bathe the client. 3. Listen to the client reminisce. 5. Weigh the client. 6. Take vital signs (1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client remininsce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not delegate routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.)

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? Select all that apply 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. (1., 2., 4 & 5. Correct: The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients to be at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply when it is time for an evaluation. 3. Incorrect: Ask the staff what they do to provide fall precautions for at risk clients does not ensure that they follow through. It will tell you if they know what should be done. The QA manager needs objective data and asking the staff is subjective data.)

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

1. Client requiring enemas and antibiotics. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes. (1., 4., & 5. Correct: Administering enemas and antibiotics to a client is within the scope of practice of the LPN. Nausea and vomiting are common side effects after a client receives chemotherapy. The LPN can administer antiemetics and monitor fluid status. It is within the scope of practice for the LPN to perform sterile dressing changes. 2. Incorrect: This client is a new admit who is in DKA and would be unstable. 3. Incorrect: This client will require frequent assessments and monitoring for postop complications.)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Empty the indwelling catheter on the four hour postop client. 2. Instruct a client to soak in a warm bath for 30 minutes when experiencing endometrial discomfort. 3. Monitor the peri-pad count on a client diagnosed with fibroid tumors. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall.

1. Empty the indwelling catheter on the four hour postop client. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall. (1., 4., & 5. Correct: The UAP can empty a client's catheter bag. UAPs can assist with elimination and are taught how to measure output. Ambulating a stable client to the bathroom is also an acceptable task to assign to the UAP. All personnel should encourage a client to ambulate when prescribed. This can be done by the UAP. 2. Incorrect: It is out of the UAP's scope of practice to teach. The RN cannot delegate teaching to anyone other than another RN. 3. Incorrect: The nurse is responsible for assessing and evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP.)

A preschooler has been hospitalized for observation. The unlicensed assistive personnel (UAP) offers to sit with the child and asks the nurse to suggest an appropriate activity. The nurse knows the best activity choice for a preschool child is what? 1. Children's television show 2. Small stacking blocks 3. A checker board game 4. Children's card game

2. Small stacking blocks (2. Correct: Preschool children, ages 3 to 5, are in the Erikson stage of "initiative versus guilt" where the learning goals involve exploration and manipulation of the environment. Motor skills are developing, and playing is used to increase self-esteem through imagination and creativity. Stacking small blocks to build structures or create creatures is definitely appropriate for this age group and can easily be done on the bedside table. 1. Incorrect: A preschool child may not have the patience to sit through an entire television show. Additionally, this would not address the developmental needs of this age group, which focuses on creative activities such as coloring, painting, playdough, or building blocks. Even hospitalized children must have their developmental needs addressed. Television may appeal more to adolescents. 3. Incorrect: Table games like checkers are more appropriate for school age children, who tend to like group activities, particularly with peers of the same age and sex. Playing checkers is too tedious and inactive for a young preschooler. 4. Incorrect: Card games, even those designed for children, are generally too boring for youngsters. Preschool children prefer activities which require imagination and activity with others. Dressing up in clothing, riding bikes, or other physical games are good for engaging this age group. In the hospital, creativity can be encouraged with drawing, chalk, or playdough.)

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

3. Taking vital signs on a client 12 hours postpartum. (3. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from Foley catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing foley catheter).

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? Select all that apply 1. Being discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. New transfer from post-anesthesia care unit (PACU) following a mastectomy.

3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. (3. & 4. Correct: An LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The client who is two days post gastric bypass has already advanced to clear liquids and would be appropriate for an LPN. Also, a client who has Alzheimer's disease awaiting transfer would have needs that could be addressed by an LPN, and therefore is a suitable assignment. 1. Incorrect: This client has a new Hickman port which is an implanted access device used for chemotherapy or medications given long term. There is a great deal of teaching necessary regarding the care of this port. This client should be assigned to an RN. 2. Incorrect: This client will need frequent assessment of circulation in the area of the DVT and monitoring for evidence of bleeding complications. Additionally, PTT levels will be drawn every 6 hours that may require the nurse to adjust the heparin infusion rate. This client is not appropriate for an LPN. 5. Incorrect: This fresh post-op client will require frequent vitals and assessment of the surgical dressing following this surgery. This client would be assigned to an RN.)

The morning assessment of a client admitted with congestive heart failure reveals a weight gain of 2.5 pounds (1.14 kg) since the previous day, crackles in lung fields bilaterally, dyspnea, sacral edema, and bounding peripheral pulses. Which prescription by the healthcare provider should be the nurse's priority? 1. Maintain accurate intake and output. 2. Restrict sodium in the diet. 3. Limit fluids to 1500 mL per day. 4. Administer furosemide 40 mg IV push.

4. Administer furosemide 40 mg IV push. (4. Correct: The client has signs of worsening fluid volume excess associated with congestive heart failure and needs something to help fix the problem. The option that will actively help to manage this is the furosemide. It is a diuretic that will hopefully help to reduce the fluid volume and improve the symptoms. 1. Incorrect: Anyone with a fluid problem, which this client obviously has, should have the intake and output monitored closely. But would this help fix this client's problem? No! So, it would not take priority over an option that would help reduce the fluid volume excess. 2. Incorrect: Although client's with fluid volume excess and clients with congestive heart failure are placed on lower sodium diets to reduce fluid retention, this option would not be a priority over the administration of an agent that could help to reduce the vascular volume. 3. Incorrect: Clients with congestive heart failure and individuals with fluid volume excess for other reasons will often be prescribed to have a limited amount of fluid intake per day. However, this would not fix the problem for this client, and the priority should be focused on removing the excess fluid by administering the diuretic.)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

4. Take a tympanic temperature on client every two hours. 6. Report client's pulse oximetry reading every hour. (4., & 6. Correct: The UAP can take vital signs (including tympanic temperatures) and pulse oximetry readings but cannot interpret these findings. This statement is telling the UAP to report the reading, which can be done by the UAP. 1. Incorrect: The nurse cannot assign assessment or evaluation to the UAP. 2. Incorrect: The UAP cannot monitor, assess, or evaluate. This requires the skills of a nurse. 3. Incorrect: The nurse cannot assign teaching to the UAP. 5. Incorrect: Postural drainage and chest physiotherapy is not a routine and frequent task. Monitoring is required during this procedure as well. This would require the care of a nurse.)

A medical surgical nurse has been floated to the pediatric unit to assist during a staffing shortage. Which clients would be most appropriate for the float nurse? Select all that apply 1. A 10 year old in sickle cell crisis. 2. A 6 month old in a croup tent. 3. A 4 month old with bronchiolitis. 4. A 2 year old with cleft palate repair. 5. A 8 year old with Crohn's disease. 6. A 4 year old with acute asthma.

1. A 10 year old in sickle cell crisis. 5. A 8 year old with Crohn's disease. 6. A 4 year old with acute asthma. (1., 5. & 6. Correct:The nurse has been floated to a pediatric unit, which not only has a special client population but also specific disease processes that are rarely encountered on an adult medical surgical unit. Client assignments should be based on both the developmental age/needs of the client and the disease process. A 10 year old sickle cell client is appropriate because school age children are more compliant and adapt easier to hospitalization than other groups; additionally, the float nurse may have had clients on the medical surgical unit with sickle cell disease. The same is true for an 8 year old with Crohn's disease: this would definitely be a safe assignment for a medical surgical nurse. Although the four year old is in the pre school group, usually parents of young children remain at the bedside to provide emotional support. Also, this nurse would have assessed and cared for asthmatics in the adult population previously. 2. Incorrect: Croup is a term used to refer to a variety of respiratory problems in children or infants. This infant's condition was serious enough to necessitate hospitalization with the use of a croup tent for oxygen and humidification. Therefore, the client's respiratory status will require close specialized monitoring by a pediatric nurse. This assignment would be unsafe for a medical surgical float nurse. 3. Incorrect: Not only is this client an infant, but the issue is a respiratory illness specific to pediatrics. Infants can deteriorate quickly, requiring specialized assessment and intervention techniques. A float nurse who is not experienced in pediatric assessments would not be appropriate for this client. 4. Incorrect: While the client's young age could prove challenging, it is the repair of a cleft palate that makes this an unsafe assignment for the float nurse. This is a specific surgery with potential airway issues, requiring particular assessment expertise not usually performed by a medical surgical nurse. This client should be assigned to a pediatric nurse.)

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1. Assist client to brush and floss teeth. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. (1., 4., & 5. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. So, the UAP can assist a client to brush and floss teeth. UAPs can assist with elimination and are taught how to measure output. This would be an acceptable task to assign to the UAP. Gathering needed equipment and supplies is within the scope of duties for the UAP. 2. Incorrect: It is out of the UAP's scope of practice to administer medication. This includes medication enemas. Only a plain enema or soap enema can be given by the UAP. 3. Incorrect: The nurse is responsible for evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 6. Incorrect: The nurse is responsible for monitoring a client. This would be out of the UAP's scope of practice. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data.)

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. (1., 2., 3., & 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 5. Incorrect. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court.)

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1. Assist the client with toileting. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. (1., 3., & 4. Correct: The UAP can provide assistance with routine activities of daily living, which includes toileting. The UAP can also walk with a client in the hallway. There is no mention that the client is having difficulty with ambulation, so there is no reason why the UAP cannot walk with the client. Orienting the client frequently can be done by all staff encountering the client. 2. Incorrect: Informing the client or family of procedures is not within the scope of practice for the UAP. 5. Incorrect: Restraints need to be put on properly, insuring that they are not applied too tightly. This is not within the scope of practice for the UAP.)

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

4. 10 year old with type 1 diabetes mellitus. (4. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 1. Incorrect: This client is only 3 months old, which would require specialized skills to evaluate developmental needs. Additionally, nonorganic failure to thrive is a serious situation in which the infant is not getting appropriate nutrition. There could be economic factors, resulting in a lack of food or poor-quality breast milk. Parental beliefs or negligence could also contribute to the situation; therefore, an RN should be assigned to this infant. 2. Incorrect: Although this client is an adolescent, an exacerbation of cystic fibrosis would require careful and frequent respiratory assessments with possible chest physiotherapy. This client would be more appropriate for an RN. 3. Incorrect: A new admission is not appropriate for a nurse sent from the medical surgical unit to the pediatric unit, particularly an LPN, because of the need for initial and frequent assessments. Epiglottitis is a respiratory illness that also impacts the airway. This child should be assigned to an RN.)

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Give magnesium citrate 296 mL at 3 PM today. (4. Correct: If you give the magnesium citrate, which is a laxative, nothing will get passed the complete blockage. The client would develop severe cramping. This could cause a medical emergency. 1. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. 2. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. This is an appropriate prescription. 3. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO.)

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? Select all that apply 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO₄ at 3g/hr IV 4. Risperidone .5mg PO daily 5. Dexlansoprazole 30 mg PO daily

1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO₄ at 3g/hr IV 4. Risperidone .5mg PO daily (1., 2., 3., & 4. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Q.d. is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. In Option #2, there is a trailing zero after the prescribed dose. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. For Option #3, you may have recognized MgSO₄ as being magnesium sulfate. It is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO₄). Administering 3 g/hr IV of morphine would be extremely dangerous. In option #4, the leading zero is missing from the prescription. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. 5. Incorrect: This prescription is written correctly.)

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Stands straight with feet together. (1. Correct: When moving a client, the most important safety action for the staff doing the lifting is to spread their feet apart to shoulder width, with knees slightly bent, to prevent back injury. The feet should never be placed together. The most stable part of the body is at the hips, and moving feet apart stabilizes the lifter. The nurse would intervene in this scenario before the UAPs are injured. 2. Incorrect: The UAPs are aware when sliding a client up in bed, if the client does not lift their head, the sudden movement could hyperextend the client's neck, causing severe trauma. The client must lift head off bed just before the staff moves the draw sheet to prevent neck injury. This is a correct action. 3. Incorrect: When moving an obese client, there should be at least two staff members on each side of the bed, grasping the draw sheet with both hands. With a firm grasp on the draw sheet, the staff then slides the client upward in the bed. The UAPs completed this action correctly. 4. Incorrect: Before moving the client upward, all staff should turn slightly toward the head of the bed, feet planted shoulder width apart and firmly grasp the draw sheet with both hands. This position is correct for both client and staff safety.)

A roommate overhears the primary healthcare provider discussing a client's laboratory results, including a positive HIV test. The roommate requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? Educate roommate about transmission of HIV and AIDS. Encourage the client to verbalize feelings regarding situation. Contact social services to address client's future needs. Transfer roommate to another location as soon as available. Notify nurse manager regarding breach in confidentiality.

Educate roommate about transmission of HIV and AIDS. Notify nurse manager regarding breach in confidentiality. Transfer roommate to another location as soon as available. Educate roommate about transmission of HIV and AIDS. Contact social services to address client's future needs. (The first action by the nurse is to address the roommate's concerns and fears about contracting HIV by presenting information regarding disease transmission. Next, since this situation represents a definite breach of confidentiality, it must then be reported to the nurse manager. Third, despite educating the roommate on modes of transmission, the nurse should attempt to honor the request to be moved to another room. Fourth, address the roommate's needs, by encouraging the client to express feelings about the diagnosis and current situation. Additionally, the client will have other needs related to the diagnosis which can best be handled by the social services department.)

After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Ask the LPN/VN how the client assignment should be adjusted. (1. Correct: Explore her concerns; this is most therapeutic and helpful response. Finding out what are LPN/VN's concerns first will help the RN address the LPN/VN's request and build trust in the healthcare team relationship. 2. Incorrect: This statement does not help the RN understand the LPN/VN's concern about the assignment, an negates the confidence in the LPN/VN's abilities and skills. 3. Incorrect: This answer does not acknowledge the LPN/VN's concern. 4. Incorrect: This action will not help address the LPN/VN's immediate concern with the assignment and makes resolution of the issue much more complicated than it should be.)

An unlicensed assistive personnel (UAP) is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse? 1. Holds chest drainage unit (CDU) at the level of the chest. 2. Disconnects the chest tube from suction. 3. Allows the client to ambulate. 4. Helps client use a walker.

1. Holds chest drainage unit (CDU) at the level of the chest. (1. Correct: The drainage system should be held below the level of the chest to promote drainage and prevent backward flow of drainage back into the pleural space. 2. Incorrect: The chest tube system can function because of gravity and does not have to be attached to suction when the client ambulates. Leaving it connected to suction would be a safety hazard as the client could trip and fall over the tubing. 3. Incorrect: There is nothing in the stem to indicate that the client cannot ambulate. Having a chest tube does not mean the client must not ambulate. 4. Incorrect: There is nothing wrong about having the client use a walker while ambulating. This could potentially prevent a fall.)

Who often performs the responsibilities of a case manager? Select all that apply 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

2. Social worker 4. Nurse (2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional. Case management is a cross-disciplinary practice. It's function is to advocate for the client. 1. Incorrect: The physical therapist focuses on one area which is the client's ability to move and perform functional activities in their daily lives. The physical therapist would not be the client's case manager. 3. Incorrect: The dietitian nutritionist focuses on one area which is human nutrition and the regulation of diet. The dietitian nutritionist would not be the client's case manager. 5. Incorrect: The unlicensed assistive personnel does not have the education and/or training for case management.)

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

3. Wipe up spilled coffee in the family waiting room. (3. Correct: When considering multiple safety issues, the priority is the situation which puts the greatest number of individuals at risk. Liquid on a floor is a fall hazard to anyone in that vicinity. A family waiting room has dozens of visitors a day, including adults, children, clergy, other staff and possibly other clients. The floor needs to be clean and dry to prevent injury. 1. Incorrect: The only individuals affected in this situation would be those staff personnel authorized to be in the medication room. In addition to the housekeeper, nursing staff can also change sharps containers. Therefore, even a nurse could replace the filled containers if need be. This action is not the first priority. 2. Incorrect: Cleaning an isolation room is a time-consuming process. Waiting until more important tasks are completed will not put anyone at risk since the room cannot be used until cleaned. Another task has first priority. 4. Incorrect: The curtains that hang around a client's bed are for the purpose of privacy. Even a malfunctioning curtain, which could be anything from torn fabric to broken hooks, does not pose a hazard. Although the client may not have complete privacy, this problem would not affect other clients. There is another issue that affects many individuals.)

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

4. Client who needs a peak blood level drawn because the antibiotic just finished infusing. (4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe. 1. Incorrect: A leaking colostomy bag is uncomfortable and should be seen, but this is not time sensitive like the peak blood level. 2. Incorrect: Pain needs assessing and treated appropriately. The key here is three days post op so the administration of the pain medication does not take priority over the need to draw the blood levels at this time. 3. Incorrect: Nutrition for a baby that is admitted for failure to thrive is important, but can wait a few minutes until blood levels are drawn.)