NCLEX Management of Care

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients.

2. Inform the nurse that refusing client care is not acceptable nursing practice. (2. Correct. This action by the charge nurse demonstrates an understanding of the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. The ethical obligation to care for all clients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral and ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. As a professional, the nurse should provide the same level of care to every client, regardless of diagnosis, skin color, ethnicity or economic status. 1. Incorrect: This is not the best action for the charge nurse to take.The charge nurse should remind the nurse of the responsibility for the agency to provide nondiscriminatory care to all clients. The re-assignment of the client to another nurse does not resolve the ethical dilemma by the nurse refusing to provide care. 3. Incorrect: The nurse can inform the employer of the reluctance to care for a certain population, but must provide strong rationale and documentation to support the necessity for refusal of the assignment. Recognition by the organization of an individual nurse's right to refuse to care for a specific client population sets a major personnel precedent and will not be made lightly. A health care agency has a responsibility to provide care for all clients accepted into the organization. Due to this responsibility the nurse cannot be guaranteed that he/she will never be asked to provide care for the client in question. 4. Incorrect: This is generally a decision made on a level beyond the charge nurse. This is a last resort after documentation and consideration by management to accept the nurse's request. If honored, the nurse should expect to be transferred. However, the nurse may encounter the situation again.)

Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? Select all that apply. 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.

1. 10 year old paraplegic in for bowel training. 4. 7 year old in Buck's traction for a femur fracture. (1. & 4. Correct: These clients have conditions that the LPN/VN can care for with little assistance from the RN. Bowel training is a health promotion, self care activity that is within the scope of practice for the LPN/VN. Buck's traction is a type of skin traction that is also within the scope of practice for the LPN/VN. 2. Incorrect: This client will probably have IV fluids prescribed that the RN will need to administer. Assessment of lung status would be important since the client is a new admit with asthma. This is a potentially unstable client and would not be appropriate for the LPN/VN. 3. Incorrect: This client, admitted with septicemia, is potentially unstable and will probably require IV antibiotics and very close monitoring due to being very young with a major infection. 5. Incorrect: This client will need close observation and the higher skill level of an RN since there is a head injury and the client spent time in the ICU only one day before.)

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Blood pressure 90/40 mm Hg Heart rate 112 beats/min Respiratory rate 32 breaths/min Temperature 103°F (39.4°C) axillary O₂ saturation 94% Notes: Heart rate irregular. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with adventitious sounds noted to left lung base. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in urinary drainage system. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.

2. Blood pressure reading. (2. Correct: The low blood pressure indicates that systemic tissue perfusion will not be adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen sat is 94%, so the adventitious lung sounds do not need immediate intervention. 3. Incorrect: The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to improve the BP. The second priority is to treat the infection.)

The critical care nurse is caring for four clients who develop rhythm changes within moments of each other. Which client (with a rhythm change from a normal sinus rhythm) should the nurse assess first? 1. Atrial Fibrillation - 100 BPM 2. Bradycardia - 40 BPM 3. PVCs - 1 per minute. 4. Atrial flutter - 80 BPM

2. Bradycardia - 40 BPM (2. Correct: Cardiac output can be decreased which decreases perfusion to the vital organs and can cause shock. This client should be assessed first. 1. Incorrect: Atrial fibrillation is usually not a life threatening situation. This is not as life threatening as the complete heart block with a slow ventricular rate. 3. Incorrect: This client has had one premature ventricular contraction (PVC) which is not life-threatening. We worry about 6 or more PVCs in one minute, and multifocal PVCs. 4. Incorrect: This is not as life threatening as the client with the slow heart rate. In atrial flutter the atria are contracting at a rate of 300 beats per minute (bmp) and at a regular rate.)

Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102°F (38.8°C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3. Three year old with wheezes in right lower lobe. (3. Correct: The child having respiratory difficulty should be seen first. This is an example of using Maslow to set priorities. Airway will always be first followed by breathing and circulation. This client is not stable. 1. Incorrect: This client will need to be seen, but not prior to a client with an immediate vital function problem such as airway and breathing. From the information given, all we know is that the child has a fracture so we have to assume the client is stable. 2. Incorrect: This client will need to be assessed, but not prior to a client with an immediate vital function problem such as airway and breathing. The temperature is elevated but there is no information to cause the nurse to think the situation is life threatening. 4. Incorrect: The tube has come out and needs to be replaced so that feeding can be resumed. You have time before this client is in any distressed so this is not your priority client.)

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? Select all that apply. 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. (1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously. 4. Incorrect: There is nothing in this option to indicate that the child is unstable. This assignment is appropriate for LPN/VN 5. Incorrect: This assignment is appropriate as the LPN/VN can provide care related to elimination needs.)

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? Select all that apply. 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen (1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suction equipment for suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker.)

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? Select all that apply. 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen (1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. The risk of respiratory compromise increases as the neurologic status deteriorates. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive due to accumulation of toxins and may need suctioning if unable to clear secretions from the oropharynx. Hepatic encephalopathy frequently has associated bleeding varices. The increasing ascites leads to hypovolemia. Both of these conditions can result in hypoxemia for the client at the end stages of liver disease; therefore, oxygen therapy is provided. 3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate, the client lapses into a coma. Therefore, the unresponsive client will not be ambulatory and would not need a walker.)

The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.

1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. (1. Correct: The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety. 2. Incorrect: Although sleeping medication may be warranted for this client, the nurse neglects to offer a viable solution to the client's problem. The nursing interventions should focus on assisting the client to explore their feelings. 3. Incorrect: Although this is a helpful response, this answer does not include notifying the case manager. The nurse should forward this request to the case manager who can identify client needs. 4. Incorrect: Calling the primary healthcare provider is inappropriate, as the client requires hospitalization now. The primary healthcare provider will determine if the client should be hospitalized.)

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1. Ask the primary healthcare provider to prescribe a diabetes educator consult. (1. Correct: Referrals to appropriate agencies or departments are often made by the home care nurse. Client needs must be met in the most efficient way while utilizing appropriate expertise. This client has poorly controlled diabetes resulting in a wound. A diabetes educator can help develop a plan to prevent further complications of diabetes. 2. Incorrect: The home care nurse has identified an immediate need which must be met. Increasing the number of visits may be part of the nurse educators plan but the total care of this client needs to be assessed. Healing is not the primary problem, poorly controlled diabetes is the problem. 3. Incorrect: Nursing home placement may or may not be needed. Other disciplines may need to be involved in the care of the client before suggesting alternate placement. Remember to fix the problem and the nurse educator will fix the poorly controlled diabetes. 4. Incorrect: Bringing in sitters for hygiene needs will not fix the problem. The problem is poorly controlled diabetes and this poor control has resulted in an open wound.)

Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.

1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen. (1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client has difficulty swallowing and is at risk for choking making the client unstable. Therefore, the nurse should not allow the UAP to feed this client.)

A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Blood cultures times two 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr

1. Blood cultures times two (1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed. 2. Incorrect: The ceftriaxone is administered after the appropriate IV has been initiated. This would be the last intervention to be initiated. 3. Incorrect: The IV can be started at any point, but should be done after the cultures so the blood sample would not be affected in anyway. 4. Incorrect: Fluids will be started after the cultures are obtained and after the IV is started so as not to alter the results of the blood work and ensure correct treatment.)

Which tasks would be appropriate for the nurse to assign to an LPN/VN? Select all that apply. 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures. (1., 2., 5., & 6. Correct. These tasks are within the PNs practice scope. The PN can change a colostomy bag, administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures. 3. Incorrect: The RN is responsible for teaching. The PN can reinforce teaching once taught by the RN. 4. Incorrect: The RN must give IV pain meds to clients. The PN can monitor the effectiveness of the medication after given by the RN and can report any problems if necessary.)

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? Select all that apply. 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented 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 is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. 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 as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation. 3. Incorrect: Asking the staff does not ensure that they follow through.)

Which client should the charge nurse assign to a new RN? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.

1. Child needing pre-operative medication prior to reduction of a fracture. (1. Correct: This is the least complicated client that could be given to a new, inexperienced nurse. Even though he client has a fracture, the focus is on giving pain medication prior to a major procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the new nurse. 3. Incorrect: This is a more complex client and is least likely to be assigned to a new nurse because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the new nurse. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis.)

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN? Select all that apply. 1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM

1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion (1., & 2. Correct: The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client. 3. Incorrect: This client is more acute and requires a higher skill level. Nursing care for this child would involve frequent neurologic assessments and monitoring for infection. The child should also be monitored for signs of possible complications including bowel perforation. 4. Incorrect: This client is more acute and requires a higher skill level. The nurse on the general pediatric unit would not be experienced in caring for a child on a ventilator. 5. Incorrect: This client is more acute and requires a higher skill level. A child who is fresh post-op following a tracheostomy is at risk for airway obstruction from thick secretions, mucous plug, blood clot or dislodgement of the tube. Cardio-respiratory arrest can occur from these complications. The child is also at risk for hemorrhage. Nursing care would include frequent suctioning as needed, monitoring for early signs of airway obstruction, and trach care. The nurse from the general pediatric unit may not have the skills required to care for this child who also has cerebral palsy which could complicate the care required.)

Which task would be appropriate for the charge nurse to assign to a LPN/VN? Select all that apply. 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.

1. Collect data on a new client admit. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. (1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN since it is a complex, high risk IV push medication and has the potential to depress the client's respiratory rate.)

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1. Ensure a do-not-resuscitate prescription has been provided. (1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes. 2. Incorrect: It is appropriate to report the client's end-of-life wishes to other care givers, but not before ensuring a DNR order is in place. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated. 4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney.)

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply. 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition. (1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client. 2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest". 4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise, always lead a decimal point with a zero (0.5).)

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients 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. Client newly diagnosed with Type 2 diabetes.

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 clients are stable and require predictable care that can be done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency. Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed generally from autoimmune disorders. Secondary adrenal insufficiency can be caused by such things as abrupt stoppage of corticosteroid medications and surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of the RN. 5. Incorrect: A newly diagnosed client may be unstable and would require assessment, care plan development and teaching for the newly diagnosed diabetic which cannot be performed by the PN.)

Which action, if done by a nurse, needs to be interrupted by the charge nurse? 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam.

1. Mixes diazepam and hydromorphone in one syringe. (1. Correct: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene. 2. Incorrect: This is an appropriate action. Food in the stomach delays absorption of diazepam so it would need to be given before meals. 3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic and can decrease level of consciousness (LOC) and increase the risk of falls, so the nurse would be taking appropriate measures to ensure the client's safety. 4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles and can decrease LOC and increase the risk of falls.)

Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.

1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." (1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1.)

Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? Select all that apply. 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section. (1. & 3. Correct: These are stable clients whose care is within the scope of practice of an LPN/VN. 2. Incorrect: This client is high risk because she is exhibiting symptoms of postpartum onset preeclampsia. 4. Incorrect: This client is considered to be at high risk since she is in labor and exhibiting symptoms of preeclampsia. This is an unstable client whose care is not within the scope of the LPN. 5. Incorrect: This client has an IV narcotic infusing which cannot be assigned to an LPN. IV narcotics are within the scope of the RN only.)

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. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off.

1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. (1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, 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. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. 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. 6. Incorrect: Quality improvement looks at improving processes and does not use intimidation and punishment to improve quality care.)

Which nurse is providing cost effective care to a client? Select all that apply. 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.

1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. (1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client.)

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.

1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. (1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk.)

The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? Select all that apply. 1. Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.

1. Speaking up for the underrepresented, such as the poor and uneducated persons. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located. (1., 3., 4. & 5. Correct: Many times factories are placed in communities where people are not aware of the hazards. The underrepresented and poor need the nurse as their advocate. Forums encourage wider participation of all community members and give the community more information about the consequences of the pollution. The public health nurse advocates for the health of the entire community. Individuals in the communities where factories are located could give first-hand information about health or other issues related to the factory placement. Printed reports, depending on the source, may contain false information. 2. Incorrect: More information is needed at this time. Placement should be determined by what is best for the community as a whole. The nurse is interested in protecting the public's health.)

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1. Undergoing surgery for placement of a central venous catheter. (1. Correct: This is the most stable client to give to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good client for a neonatal nurse because knowledge of lab values, chemotherapy precautions, protective isolation and chemotherapy drugs is required for the nurse in order to care for this client. 3. Incorrect: This is not the best client for a neonatal nurse because thrombosis problems are not commonly seen in the nursery. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled observation and assessment using the Glasgow Scale. This level of assessment is not utilized in a neonatal unit.)

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. (1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The tapes are received from sources where reliability of information is provided. This is the most reliable option for providing accurate information. 2. Incorrect: This is not the best option. Some pre-surgical procedure may be difficult to draw or difficult for the client to understand what was drawn. There is no way to know if the client is understanding what the nurse is trying to communicate through the pictures. Client safety could be compromised if decisions are made based on inaccurate perceptions. 3. Incorrect: This is called "Getting by" and may have to be used when the nurse cannot speak the client's language, and there are no interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option and should be used only if other more reliable means for interpreting are not available. 4. Incorrect: Disadvantages of using ad hoc interpreters include compromising the client's right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate. This may have to be done at times if tapes or other reliable means of interpreting are not available. However, this is not the best option.)

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."

2. "I had rheumatic fever when I was 10 years old." (2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence. 1. Incorrect: Chicken pox would have no implications on this surgery. 3. Incorrect: Cancer history in the family would have no implications for this surgery. 4. Incorrect: Pain in the hip is likely the reason for the surgery.)

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? Select all that apply. 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"

2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?" (2., 3., 4., & 5. Correct: First, the nurse should identify self, agency, and client calling about. Then deliver SBAR. The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare, effortlessly structuring critical information primarily for spoken delivery. Each of these statements fulfills appropriate SBAR requirements. 1. Incorrect. The nurse should identify the primary healthcare provider by name and should then identify self, the agency the nurse is calling from and the client by name. For instance: "Dr. Smith, this is nurse Adams, RN. I am calling about your client, Jane Doe, at ABC hospital.")

The nurse is working at the triage station. Which client should the nurse triage first? 1. A client with hepatitis A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain.

2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " (2. Correct: The client who has a cast with unrelieved severe pain indicates compartment syndrome and requires immediate action. This client is at greatest risk for harm because untreated compartment syndrome can cause irreparable nerve, and muscle damage and can lead to amputation. 1. Incorrect: A client with hepatitis A is not the highest priority at this time. The itching is most likely caused by accumulation of bile salts under the skin. The client will need to be evaluated but is not the triage nurse's highest priority. 3. Incorrect: This client would need to be seen and evaluated for dehydration. Of the clients listed here, this is not the triage nurse's highest priority. 4. Incorrect: When you see hematuria it leads you to worry about bleeding. Remember that even though hematuria may seem that the client is losing a lot of blood, it is not a significant loss. Hematuria is probably due to a kidney stone, infection, trauma or even prostate problems. In this triage scenario it is the lowest priority.)

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department.

2. Begin treatment by inserting two large bore IVs of Normal Saline. (2. Correct: In emergencies, if it is impossible to obtain consent from the client or an authorized person, a health care provider may perform a procedure required to benefit the client or save a life without liability for failure to obtain consent. In such cases the law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent. 4. Incorrect: Consent for a minor is not needed in the event of an emergency. This is an emergency, so begin treatment for DKA.)

Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia.

2. Client diagnosed with seizure disorder. (2. Correct: OB nurses would have the appropriate knowledge needed to care for a client with a seizure disorders, because they care for clients who have eclampsia (seizures). 1. Incorrect: This client might have tuberculosis (TB) and is not a good choice to move to the OB floor, because of the risk for transmission of an infectious disease. 3. Incorrect: This client is not the best one to be transferred to the OB floor, because these nurses do not routinely care for clients with a new pacemaker. The client is also likely to remain on a cardiac monitor until discharge. 4. Incorrect: This client is at risk for fluid volume overload since there is a history of heart failure and would require close monitoring while receiving a blood transfusion.)

Which client should the nurse place in the room with a 6 year old with glomerulonephritis? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Four year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Two year old who has a fractured tibia.

2. Four year old with nephrotic syndrome. (2. Correct. This child is not infectious and could be placed in the room with the child who has glomerulonephritis. Since the children are close in age, they will adapt well together. 1. Incorrect. Respiratory syncytial virus (RSV) is a common and highly contagious virus that infects the respiratory tract of many children before their second birthday. This client requires contact and droplet precautions and should not be in the room with the client who has glomerulonephritis. 3. Incorrect. Febrile seizures are one of the most common neurologic childhood problems often caused by a fever with a viral infection. Although the underlying infection is not identified, this child with a probable infection should not be placed in the room with the client with glomerulonephritis. 4. Incorrect. Although this child is not infectious, it is not the best option because the child is too young to be in the room with the 6 year old. Place children within the same age group together whenever possible.)

A nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include? Select all that apply. 1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time.

2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. (2., 3. & 4. Correct: HIPAA is federal legislation enacted to protect client health information and privacy. Any information the client reveals to healthcare personnel must be kept confidential. Clients have the right to access their personal healthcare records and to obtain copies of the records. A client's health information can be revealed only with the client's permission, or when a healthcare provider or facility is required to do so by law. 1. Incorrect: Healthcare personnel do not have the right to access a client's medical records or health information without treatment necessity. 5. Incorrect: Unlicensed assistive personnel do not have the right to access a client's medical record or health information.)

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2. Inform the family and ask them to remove the guns. (2. Correct: The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital. 1. Incorrect: This is appropriate; however, client safety is priority at this time. Suicide risk is higher when a plan is expressed and lethal means are available. 3. Incorrect: Charting the thinking pattern is an appropriate action; however, the priority at this time is the client's safety. Suicide risk is higher when a plan is expressed and lethal means are available. Making a follow up appointment would be delaying care for the immediate action that is needed to protect the client. 4. Incorrect: Suicide risk is higher when a plan is made and lethal means are available. Asking the client to return to the clinic tomorrow would be delaying care for the immediate action that is needed to protect the client. It is likely that this client will be admitted directly to the hospital.)

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2. Insert a urinary catheter for hourly urinary outputs. (2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform. 1. Incorrect. The UAP can do this task as well as the LPN. In order to be most effective with the nurse's time, this task can be delegated to the UAP. 3. Incorrect. The RN with special training can insert a PICC line. The LPN cannot complete this task. 4. Incorrect. The RN must complete this task. The LPN should not initiate PCA morphine.)

Which statements should a nurse make when educating a client about advance directives? Select all that apply. 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. (2., 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions. 1. Incorrect: The family's wishes for treatment of the client do not take the place of or negate the client's advance directive. 5. Incorrect: The spouse's wishes for treatment of the client do not take the place of or negate the client's advance directive.)

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2. Listen to the family's concerns and report those to the primary healthcare provider. (2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate. 1. Incorrect: The nurse should not impose personal values on the client and family. Cultures vary as to acceptance of nursing home placement. 3. Incorrect: The client may not be in a position to make this decision. 4. Incorrect: The nurse must serve as client advocate and intermediary between client/family and primary healthcare provider as decisions are made about this important issue.)

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school.

2. Look up how to perform the procedure in the policy and procedure manual. (2. Correct. The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with an experienced nurse and ask the nurse to observe the new nurse while inserting the feeding tube. 1. Incorrect. This is passive and would not benefit the new nurse to strengthen the skills. The best action would be to look up how to do the procedure, discuss with another nurse, and ask that nurse to observe the insertion of the feeding tube. 3. Incorrect. This is not the best option. The new nurse needs to insert the feeding tube in order to become more proficient with this skill. This option will not help the new nurse gain confidence in nursing skills. 4. Incorrect. Although the new nurse should have the basic knowledge of feeding tube insertion, the nurse should follow agency policy and procedure. It is then best to discuss the procedure with another nurse and ask the nurse to observe the feeding tube insertion since this nurse has never performed the skill.)

The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? Select all that apply. 1. Document the medication with times and doses to be given, then administer the medication as ordered. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.

2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. (2., 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety. 1. Incorrect: No, this medication could cause harm to the client. The client is allergic to this medication. 5. Incorrect: No, the primary healthcare provider, not the pharmacy, should be notified for medication changes. The primary healthcare provider is responsible for prescribing the medication.)

Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence. (2., 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks. 1. Incorrect: The UAP cannot provide teaching; that is planned and implemented by the RN. 3. Incorrect: This is out of the scope of practice for the UAP as it is requires entering a sterile system using sterile technique. 5. Incorrect: The UAP does not have the knowledge and skill to irrigate catheters of any kind. This is a skilled procedure.)

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2. Suggest that the new nurse reconsider the client's developmental needs. (2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1., & 3. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client.)

A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient.

2. Takes offense to the abrupt nature of the treatment. (2. Correct: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity. 1. Incorrect: The nurse is not demonstrating cultural sensitivity. The family is not likely to accept this abrupt approach due to the cultural differences related to time and the desire for more genuine personal interaction. The Hispanic mother may be offended by the direct interviewing approach of the nurse. 3. Incorrect: The mother is likely to be offended with this abrupt response. Efficiency is not a priority as much as attentiveness and care, particularly with an ill child. The cultural frame of reference is present time in which other events should not interfere with the present situation. Expectations for genuine, personal interaction are also a part of the culture. 4. Incorrect: The mother is likely to interpret the nurse's actions as rude. The American culture is future time oriented and desires efficiency; the Hispanic culture is more interested in relationships and what is occurring at the present time.)

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.

3. A copy of the record may be obtained within 24 hours of the request. (3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention. 1. Incorrect: This response dismisses the client's feelings and may only anger the client further. The response does not address the reason for the client's anger. The statement may be true; however, the client does have the right to request and receive a copy of the medical record. 2. Incorrect: The primary healthcare provider does not have to be contacted, as there should be policies in place to grant the request for a copy of the medical record. Also, telling the client to speak to the healthcare provider would not address the reason for the client's anger. This would dismiss the client's feelings. 4. Incorrect: The client has a right to the medical record. Records may also be requested by other providers with consent of the client. The client's feelings should be addressed and the client should be informed that the medical record will be provided as requested.)

The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis.

3. Client who has a fractured hip. (3. Correct: The client with Cushing's disease could go in the room with the client who has a fractured hip, as this client does not have an infection. 1. Incorrect: Both of these clients are immunocompromised and should not share a room with each other. 2. Incorrect: The client with gastroenteritis poses a risk of infection to the client with Cushing's disease because this client is immunosuppressed. 4. Incorrect: The client with bronchitis poses a risk of infection to the client with Cushing's disease.)

Which client requires immediate intervention by the nurse? 1. Client diagnosed with Crohn's disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 3. Client with a fractured femur reporting sharp chest pain of 4/10. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10.

3. Client with a fractured femur reporting sharp chest pain of 4/10. (3. Correct: Sharp chest pain after a fractured femur could indicate a pulmonary embolus (PE) or a fat embolus and requires immediate intervention by the nurse. 1. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority, although this client would be closely monitored for fluid and electrolyte imbalances. 2. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority. Just remember, pain never killed anybody. 4. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority. Although this client's pain does not need to be ignored, it doesn't take priority over someone with an embolus.)

Which client should the nurse, working the Emergency Department (ED), see first? 1. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. 2. Client who is a diabetic and has an infected sore on the foot. 3. Client with adrenal insufficiency who feels weak. 4. Client with a fracture of the forearm that has been placed in a splint.

3. Client with adrenal insufficiency who feels weak. (3. Correct: Adrenal insufficiency with weakness think shock first. This is a client that does not have enough of all their steroids, including glucocorticoids, mineralocorticoids or sex hormones. The most pertinent of these is aldosterone, which causes loss of sodium and water, and leads to shock (fluid volume deficit). Since the client is feeling weak, this is a clear sign of fluid volume deficit (FVD) and potentially for shock. 1. Incorrect: Symptoms of Chronic Obstructive Pulmonary Disease (COPD), include a non-productive cough, because of the chronic inflammation and mucous in the lungs. 2. Incorrect: The presenting problem is the infected sore on the foot, not the client's diabetes. This is not an emergency situation. Therefore, this client would not be the priority. 4. Incorrect: Since the arm is splinted, the client is stable until further assessments and treatments can be completed, such as x-rays, medications, and casting. The client would not be seen first in this situation.)

The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.

3. Client's last menstrual period was 8 weeks ago. (3. Correct: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options they are all possible but only one is a priority and in this case life threatening. 1. Incorrect: Adequate caregivers can be discussed with the client without contacting the primary healthcare provider. This is important but not the priority to report to the surgeon. 2. Incorrect: Every person who has a surgical wound is at risk for dehiscence especially in the first two weeks after surgery. Educate the client concerning signs and symptoms and causes of dehiscence but this is not your priority here. 4. Incorrect: The client's postoperative pain control will be discussed both before and post surgery. Always discuss clients concerns prior to surgery and consult the primary healthcare provider if you are unable to satisfy the client.)

What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.

3. Client's plan for transportation and care at home. (3. Correct: After outpatient surgery, the client should not be allowed to drive home. A driver and assistance at home are necessary prior to discharge. 1. Incorrect: The client's prior experience would be a factor in the pre-operative phase. 2. Incorrect: The medical plan's coverage would not be assessed by the business office in the planning phase. This is done several days or weeks prior to the scheduled surgery. 4. Incorrect: It would be atypical for the client to spend the night in a surgical clinic, as they are not generally open at night for overnight medical stay.)

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.

3. Discuss client rights with the primary healthcare provider. (3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is that deception is involved. Deceit is harmful to both clients and healthcare professionals. 1. Incorrect: This is causing an ethical dilemma for the nurse. The nurse is now lying to the client by giving the placebo which is clearly wrong. The client is not aware that the solution administered is sterile saline. 2. Incorrect: Obtaining pre-filled syringes does not correct the ethical dilemma faced by the nurse and does nothing to fix the problem. 4. Incorrect: Telling the client will cause mistrust. It is best to discuss the issue with the primary healthcare provider. A discussion with the primary healthcare provider concerning the saline order should occur prior to any discussion with the client.)

Which clients would be appropriate for the RN to assign to an LPN/LVN? Select all that apply. 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.

3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath. (3., 4., & 6. Correct: The client who is five days post CVA is one of the most stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable so this client can be assigned to the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable. 1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the RN is responsible for teaching. 2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN. 5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN.)

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. 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: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1., 2., & 4. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.)

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3. Serving the diet tray for a diabetic client. (3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform. 1. Incorrect: Teaching is the responsibility of the RN and cannot be delegated to a LPN nor a non-licensed personnel. 2. Incorrect: Changing the colostomy bag on a client will need someone with the experience/skill of performing this task. Although some agencies allow UAP's to change colostomy bags, there may be further assessment needed associated with the ostomy, such as skin condition around the ostomy. This would not be the best option to assign to the UAP. 4. Incorrect: UAPs can take VS, but they must be very cautious in order to note changes and the client receiving blood should be assessed for any s/s of reaction. Therefore, it would be best for the licensed personnel to obtain the initial v/s prior to blood administration to assess the client's status and have a baseline for evaluating the client's response to the blood administration.)

A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux.)

3. Six year old admitted for evaluation of possible sexual abuse by a parent (3. Correct: The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level. 1. Incorrect: A nurse on an adult unit should understand classification of burns and associated care for the burn client. The pediatric burned client would be a similar to the condition adults might acquire, and the nurse's skill level could transfer to these clients. 2. Incorrect: The nurse who works on an adult unit should understand the concepts for caring for a client with a fracture. The pediatric client with the fracture would be a similar condition adults might acquire, and the nurse's skill level could transfer to these clients. 4. Incorrect: The 2 month old with BPD is different, but the concept and care of reflux is similar to that in adult clients.)

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis. (4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have, it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no identified contraindications to taking care of the client with shingles. 1., 2., & 3. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles.)

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).

4. Administer furosemide 20 mg intravenous push (IVP). (4. Correct: The client is developing pulmonary edema or heart failure and needs to be diuresed to remove excess fluid. The question stem tells you that you have prescriptions for these four options so what are you going to do first. All prescriptions are possible but furosemide will fix the problem. 1. Incorrect: You may need to draw these to evaluate the effect of the fluid on oxygenation but this option will not be priority over removing the fluid. 2. Incorrect: Compression hose will help prevent stagnation of blood in the lower extremities to prevent deep vein thrombosis (DVT). Great nursing care but not priority when fluid is developing in the lungs. 3. Incorrect: The indwelling catheter can be inserted after administration of the diuretic. You will be glad you have that indwelling catheter but it is not the prescription that will help with the fluid overload problem.)

What task by the RN should be performed first? 1. Changing a burn dressing that is scheduled every four hours. 2. Administering scheduled IV antibiotic. 3. Teaching a new diagnosed diabetic about diet and exercise. 4. Assessing a newly admitted client.

4. Assessing a newly admitted client. (4. Correct: The admit assessment should be done first. It is important to initiate the assessment and physical exam within one hour of being admitted to the unit or floor. The assessment and plan of care should be completed within 8 hours of admission. 1. Incorrect: The other clients' needs are important, but are scheduled and established in a routine. These routines can be continued once the new client's assessment has been completed. 2. Incorrect: This is not a priority based on the information in the question. The scheduled IV antibiotic administration can be administered within the appropriate time frame. 3. Incorrect: A newly diagnosed diabetic is not always ready for teaching, so this is not priority. The nurse should identify when the client is ready to learn. This teaching session can occur prior to or after assessing the new client.)

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled.

4. Call the surgical area and explain that the surgery will have to be cancelled. (4. Correct: The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgment and decision-making capacity. 1. Incorrect: The client's verbal understanding does not override the fact that he has received medication that can alter thought processes and decision-making. 2. Incorrect: Witnessing would not make this document legal. The consent would not be valid because the client has already received the pain medication that could alter the thought process. 3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate.)

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Case manager

4. Case manager (4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client. 1. Incorrect: The clinical nutritionist is a member of the multi-disciplinary team, but does not coordinate and organize the delivery of care outside of the client's nutritional needs. 2. Incorrect: The primary nurse each shift develops and executes the plan of care for the client, but is not the organizer and coordinator of all the services to the client. 3. Incorrect: The primary healthcare provider is a member of the multi-disciplinary team, but is responsible for prescribing healthcare for the client, not organizing the services.)

Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation.

4. Client with abdominal discomfort and a rigid abdomen on palpation. (4. Correct. A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress. 1. Incorrect. Although this condition may be uncomfortable and could lead to renal problems if not resolved, it does not take priority over a client who is bleeding. 2. Incorrect. This person is likely experiencing pain, but this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing into the peritoneum. Remember, pain never killed anyone. 3. Incorrect. This client with a corneal laceration would be experiencing pain and needs attention to avoid vision loss. However, this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing in the peritoneum. Remember, ascites is fluid in the peritoneal cavity.)

Which client could the charge nurse assign to an LPN/VN? 1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction

4. Five year old in skeletal traction (4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly, the other clients could have intravenous fluid (IVF) needs and medications that would require skill from an RN. 1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for other problems such as dehydration and electrolyte disturbances. Therefore, the child will need close observation and the RN's assessment skills. 2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis. Assessment of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain management is also very important in these clients. Therefore, the child with sickle cell will need close observation and the RN's assessment skills. 3. Incorrect: The baby with dehydration will need close observation and the RN's assessment skills, including monitoring for impending shock. Renal function and electrolyte levels should be monitored closely. The care of the child will likely involve IV fluids.)

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101ºF (38.05°C)

4. Postpartum client 32 hours after delivery with a temperature of 101ºF (38.05°C) (4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected.)

A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client with twins at 28 weeks gestation.

4. Pre-term labor client with twins at 28 weeks gestation. (4. Correct: Both clients are presenting with the possibility of preterm deliveries. The room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure. 1. Incorrect: The client will require frequent postpartum assessments and nursing care. The client will likely have a great deal of activity in her room and this would be potentially harmful to the newly admitted client. 2. Incorrect: This client will have a increase of activities in her room as the preterm labor progresses. There is also the potential of an emergency delivery. 3. Incorrect: The client is admitted with placenta previa. Emergency deliveries may occur if the client becomes hypovolemic or there are signs of fetal compromise.)

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing. (4. Correct: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD). 1. Incorrect: This is a stable client, so no indication of immediate distress is indicated. A small amount of drainage on the dressing of a client who had a appendectomy 3 hours ago would not be assessed first. 2. Incorrect: This is a stable client because confusion is part of Alzheimer's disease. Safety issues for a confused client should be evaluated. The client with dehydration is exhibiting possible manifestations of decreased oxygen level and/or fluid volume deficit (FVD) and should be assessed first. 3. Incorrect: This is a stable client with no indication of immediate distress. Crust forming on the Steinmann pins should be removed from the pin insertion site, however, this client would not be given priority over the client with dehydration.)

A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Bulb suction excessive mucus. Place identification bands on newborn and mom. Assess newborn's airway and breathing. Assess newborn's heart rate. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin. (Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30-60 breaths a minute. Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress. Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs. Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation. Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would never be a priority over Maslow's hierarchy of needs.)

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. Insert another IV line. Obtain blood sugar level. Repeat vital sign checks Initiate oxygen. Insert NG tube.

Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks (First, initiate oxygen. The client is anxious and has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid resuscitation can continue.This increased volume will improve the blood pressure. More volume, more pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar. Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the priority line of the available options. You have addressed air and circulation, so blood glucose would be next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing actions.)

The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restrictive to most restrictive? Place in correct order from least restrictive to most restrictive. Use four point soft cloth restraints. Walk the client out to the courtyard. Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. Take the client to the quiet room for a time out. Place client in the isolation room with staff observation. Restrain client's arms with wrist restraints.

Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. Walk the client out to the courtyard. Take the client to the quiet room for a time out. Place client in the isolation room with staff observation. Restrain client's arms with wrist restraints. Use four point soft cloth restraints. (First, verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client's arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive.)