NCLEX Practice Leadership

Unlicensed Assistive Personnel (UAP) What to delegate?

Transport patients, remind patient to put on CPAP at bedtime, empty catheter, measure intake & output, ambulate stable patient, encourage patient to follow prescription, re-apply compression devices, set up suction equipment, reposition patients, passive ROM, encourage patient to vent, maintain HOB position, assist w/feeding, remind about teaching, Oral care, gather supplies, vital signs (not first post-op), prepare a sitz bath, report pain (do not monitor or Gag relflex), disconnect NG tube for ambulation, (do not empty),feeding, assist w/walker, hodl chest tube drainage at level of chest, anti-embolism stockings, drain colostomy bag, bathe patient, listen to patient, take weight & height, re-orient patient, clip nails, assist with menu, replace heel protectors, clean NG tube nares, prep patient room

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

4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. 2. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. 3. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. 4. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab.

Correct Order: 2, 1, 4, 3 Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. All these clients have a respiratory problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the one diagnosed with pneumonia who has a pulse oximetry reading of 90%. A pulse oximeter oxygen saturation level of 94-99% is considered normal for most healthy individuals. A level of 92 percent indicates potential hypoxemia, or deficiency in oxygen reaching tissues in the body. Supplementary oxygen should be used if SpO2 level falls below 90%, which is unacceptable for a prolonged period. The second client that should be assessed by the nurse is the client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Normal arterial oxygen level is 80-100%. Although 89% is within normal range, it is on the low side of normal. The nurse should assess the client for potential respiratory complications. The third client the nurse needs to see is the client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Sputum specimens need to go to the lab in a timely manner. The nurse could assign the UAP to this task. In any case, the nurse should assess this client third. The fourth client the nurse should assess is the client with the clogged feeding tube. Clogged feeding tubes occur with regularity. Delay in feeding a client will not result in permanent damage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1., 2., 3., 4., & 6. Correct. Each of these actions can be taken by the nurse manager. The staff needs further education, reminders, and follow-up observation. Posters are great reminders of concepts. All nurses need to supervise those under their direction. Testing can be done as pretest or post test along with in service education. Staff development or in service sessions are required by Joint Commission on Accreditation of Healthcare Organizations (JCHO) on infection control. 5. Incorrect. This is not the best solution, because most people want to do what is right. Education should be tried first, then documentation of the infractions. You must support, supervise and educate!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? 1. Infant having a tonic-clonic seizure. 2. Child who has a laceration to the hand with bleeding controlled by pressure. 3. Teenager with a blood glucose of 108 mg/dL (6 mmol/L). 4. Adult reporting right lower quadrant abdominal pain. 5. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale.

Correct Order: 1, 5, 4, 2, 3 Infant having a tonic-clonic seizure. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. Adult reporting right lower quadrant abdominal pain. Child who has a laceration to the hand with bleeding controlled by pressure. Teenager with a blood glucose of 108 mg/dL (6 mmol/L).

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? 1. Client reporting a headache and has a fruity breath. 2. Client scheduled for a dressing change to foot ulcer. 3. Client eating a simple-carb snack due to weakness. 4. Client to receive dietary education.

Correct Order: 1, 3, 2, 4 The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Remember, pick the killer answer first! This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). What was the hint? Fruity breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.

A roommate overhears the primary healthcare provider discussing a client's laboratory results, including a positive HIV test. The roommate requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? 1. Encourage the client to verbalize feelings regarding situation. 2. Educate roommate about transmission of HIV and AIDS. 3. Notify nurse manager regarding breach in confidentiality. 4. Transfer roommate to another location as soon as available. 5. Contact social services to address client's future needs.

Correct Order: 2, 3, 4, 1, 5 Educate roommate about transmission of HIV and AIDS. Notify nurse manager regarding breach in confidentiality. Transfer roommate to another location as soon as available. Encourage the client to verbalize feelings regarding situation. Contact social services to address client's future needs.

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1) Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 2) Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 3) Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 4) Elderly client admitted 30 minutes ago with reports of constipation for four days.

Correct Order: 4, 1, 2, 3 Elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. All these clients have a GI problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This is an elderly client who is a new admit. The client reports constipation for 4 days which may be an indication of worse problems. The client is considered unstable until assessed by the nurse. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Did you think dehydration and fluid volume deficit? The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This is normal for clients with hemorrhoids. But the client does need to be assessed prior to the client with Crohn's disease who is improving. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Semi-formed stools are great news! The client is getting better. During exacerbation, the client will have many diarrhea stools.

Licensed Personnel Nurse (LPN) What to delegate?

Stable patients. Give enemas, antibiotics, anti-emetics, sub q meds, (no pain meds), monitor fluid status, sterile dressing change, wound care, monitor behavior changes, check environment for hazards, reinforce teaching, gather data, ambulate, nebulizer treatments, insert & monitor NG tubes, bolus feeding gastro tube, change colostomy bag, Call provider about lab results

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

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

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

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

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). 2. Client one day post splenectomy. 3. Client diagnosed with cancer who is crying and states, "I am not ready to die". 4. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk. 5. Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen.

Correct Order: 1, 2, 3, 5, 4 Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Client one day post splenectomy. Client diagnosed with cancer who is crying and states, "I am not ready to die". Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk.

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. 1. Elderly client who fell and fractured the left femoral neck. 2. Client who has multiple injuries from a motor vehicle accident. 3. Female client stating she has been raped. 4. Client reporting epigastric pain and nausea after eating.

Correct Order: 2, 1, 3, 4 Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Female client stating she has been raped. Client reporting epigastric pain and nausea after eating.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. 1. Client with traumatic amputations with agonal respirations. 2. Client with an open chest wound that is beginning to show signs of tracheal deviation. 3. Client with blunt trauma to the spine that is unable to move extremities. 4. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding.

Correct Order: 2, 3, 4, 1 Client with an open chest wound that is beginning to show signs of tracheal deviation. Client with blunt trauma to the spine that is unable to move extremities. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. Client with traumatic amputations with agonal respirations.

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

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

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

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

The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients? 1. The client with facial burns 3 days ago who has been crying since recent visitors left. 2. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. 3. The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. 4. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L.

Correct Order: 3, 4, 2, 1 The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client with facial burns 3 days ago who has been crying since recent visitors left. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. "Who could die if I do not see them first?" The nurse should first see is the client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. This client has a fever and hypotension, indicative of life threatening complications of shock. In this case, septic shock. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L should be seen second. This client is at risk for heart problems (dysrhythmias) with the electrical burn and the elevated potassium level. The third client the nurse should see is the client reporting pain 7/10. The nurse needs to administer pain medication. However, remember that pain never killed anyone. Take care of the other two client first. This are at risk for death. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the most stable.

In what order should the home health nurse see assigned clients? Place in priority order. 1. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. 2. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. 3. Client diagnosed with rheumatoid arthritis who requires an occupational consult. 4. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information.

Correct Order: 1, 2, 4, 3 Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Client diagnosed with rheumatoid arthritis who requires an occupational consult.

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. 1. Thermal burns covering 30% of body surface area (BSA) 2 days ago 2. Laparoscopic exploration of right knee 2 days ago 3. Total hip prosthetic device placement 3 days ago 4. Indwelling foley catheter inserted the previous day

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

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. 1. Alert the Unit Manager. 2. Report what happened to the health care provider. 3. Complete an incident report. 4. Obtain the client's vitals.

Correct Order: 4, 2, 1, 3 Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report. The first priority in such a situation is to check the client for any immediate problems secondary to receiving the incorrect medication and obtain a set of vitals. The client status is always your priority. Second, the nurse should notify the Health Care Provider of what happened, and implement any counter measures that may be ordered. Third, the Unit manager must be informed of this occurrence, allowing for a review of medication administration protocols and policies. This person is contacted after the client is stable. Take care of the client first. Fourth, the nurse will complete an incident report, per the facility's protocol, to assist in the identification and correction of any safety issues regarding the administration of medications.

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

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

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? 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

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

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

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

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

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