prioritization and delegation book

1 Elderly clients diagnosed with pneumonia may not present with the "normal" symptoms, such as fever. The client's increased restlessness may indicate a decrease in oxygen to the brain. This client should be seen first.

Which client should the medical unit nurse assess first after receiving the shift report? 1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. 2. The 25-year-old client diagnosed with influenza who is febrile and has a headache. 3. The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. 4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose.

1 This client may be having phantom pain, but it must be assessed and the client must be medicated. The nurse should assess this client first.

Which client should the nurse assess first after receiving the shift report? 1. The client with a right above-the-knee amputation who is complaining of right foot pain. 2. The client with arterial hypertension who is complaining of a severe headache. 3. The client with lymphedema who has 4+ pitting edema of the left lower leg. 4. The client with gangrene of the right foot who has a foul-smelling discharge.

1 These are signs of myxedema coma, which is characterized by subnormal temperature, hypotension, and hypoventilation. This client should be seen first by the nurse.

Which client should the nurse on the endocrinology unit assess first? 1. The client with hypothyroidism whose vital signs are T 94.2, AP 48, RR 14, B/P 90/68. 2. The client with hypoparathyroidism who has a positive Chvostek's sign. 3. The client who is 1 day postoperative thyroidectomy who is hoarse. 4. The client with diabetes insipidus who is drinking large amounts of water.

3 Have the client demonstrate the skill to ensure the client can correctly perform the glucometer reading. This is the priority when teaching about glucometer checks.

Which priority intervention should the nurse implement when teaching the client with type 2 diabetes about glucometer checks? 1. Instruct the client to keep a written record of the glucometer readings. 2. Recommend the client check the glucometer reading in the morning. 3. Have the client demonstrate how to correctly perform the glucometer reading. 4. Tell the client to dispose of the lancets and strips appropriately.

4 The UAP can transfer the client from the bed to the chair three times a day.

Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? 1. Changing the client's subclavian dressing. 2. Reinserting the client's Foley catheter. 3. Demonstrating ambulation with a walker. 4. Getting the client up in a chair three times a day.

3 The UAP can empty feces from a colostomy bag; this is not changing the colostomy bag, just emptying the feces.

Which task would be most appropriate for the nurse on the GI unit to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to draw the serum liver function test. 2. Ask the UAP to remove the nasogastric tube. 3. Tell the UAP to empty the client's colostomy bag. 4. Instruct the UAP to assist the unit secretary to transcribe HCP orders.

1 Credé's maneuver is a method used for expressing urine by pressing the hand on the bladder, especially a paralyzed bladder. It is a non-invasive procedure and should be implemented first prior to catheterization, which is an invasive procedure.

Which intervention should the nurse implement first when assisting a client with a flaccid bladder to urinate? 1. Perform the Credé's maneuver on the client. 2. Perform intermittent catheterization on the client. 3. Place the client on the bedside commode. 4. Request the client to drink a full glass of water.

1 The priority intervention is to restrict fluids to help prevent weight gain, edema, or a serum sodium decline.

Which priority intervention should the nurse implement for the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Maintain the prescribed daily fluid restriction. 2. Position the client's head of bed with no more than 10 degrees of elevation. 3. Turn and reposition the client every 2 hours while on bed rest. 4. Provide frequent oral hygiene every 2 hours for the client.

3 A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate.

The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? 1. Assign an RN to perform all sterile procedures. 2. Assign an LPN to give all IV medications. 3. Assign an UAP to complete the a.m. care. 4. Assign an LPN to write the care plans.

2 The nurse should stop the UAP from using the arm with the graft. Pressure on the graft could occlude the graft.

The client diagnosed with chronic kidney disease (CKD), and who has a left forearm graft, is assigned to the nurse and unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the nurse? 1. The UAP avoids using soap while bathing the client. 2. The UAP takes the BP on the client's left arm. 3. The UAP tells the client she should not eat chips. 4. The UAP measures a scant amount of urine in the BSC.

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

The home health (HH) agency Chief Nursing Officer (CNO) is making assignments for the nurses. Which client should be assigned to the new graduate nurse who just completed orientation? 1. The client diagnosed with Cushing's syndrome who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled. 3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

2, 3 2. The blood administration set is changed after every two units. 3. The nurse must assess the client's vital signs before every unit of blood is administered.

The nurse is preparing to administer the third unit of packed red blood cells (PRBCs) to a client with a ruptured aortic aneurysm. Which interventions should the nurse implement? Select all that apply. 1. Hang a bag of D5NS to keep open (TKO). 2. Change the blood administration set. 3. Check the client's current vital signs. 4. Assess for allergies to blood products. 5. Obtain a blood warmer for the blood

3 The client cannot learn if he has any questions or concerns. Therefore, the first intervention is to ask the client whether he has any questions. The nurse must allay any of the client's concerns or fears before beginning to teach the client.

The nurse is preparing to teach the male client how to irrigate his sigmoid colostomy. Which intervention should the nurse implement first? 1. Demonstrate the procedure on a model. 2. Provide the client with written instructions. 3. Ask the client whether he has any questions. 4. Show the client all of the equipment needed.

2 Hematuria is not uncommon after removal of a kidney stone, but cause for further assessment by the nurse. It may indicate hemorrhaging, which is life threatening.

The client had surgery to remove a kidney stone. Which of the following laboratory assessment data warrants intervention by the nurse? 1. A serum potassium level of 5.2 mEq/L. 2. A urinalysis showing blood in the urine. 3. A creatinine level of 1.2 mg/100 mL. 4. A white blood cell count of 9,500 mm/dL.

1 Cataracts cause less light to be filtered through an opaque lens to the retina. The client should have as much light as possible in the home to prevent falls.

The clinic nurse is providing discharge instructions to an elderly client diagnosed with cataracts. Which intervention is most important for the nurse to implement? 1. Teach the client to increase the light in the home. 2. Encourage the client to wear dark glasses outside. 3. Discuss the need to have the cataracts removed. 4. Tell the family not to rearrange furniture in the home.

1 The elderly client should be called first so that the nurse can determine whether the dizziness when getting up is the result of medication or some other reason. Orthostatic hypotension can be life threatening; therefore, this client may need to be assessed immediately.

The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first? 1. The elderly client with pneumonia who reports being dizzy when getting up. 2. The client with cystic fibrosis who needs a prescription for pancreatic enzymes. 3. The client with lung cancer on chemotherapy who reports nausea. 4. The client with pertussis who reports coughing spells so severe that they cause vomiting.

1 The normal hemoglobin level is 12 to15 g/dL, and normal hematocrit is 39% to 45%. This client's H&H is low. The nurse should contact the client and make an immediate appointment.

The clinic nurse is reviewing laboratory results for clients seen in the clinic. Which client requires additional assessment by the nurse? 1. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%. 2. The client who has a WBC count of 9.0 mm3. 3. The client who has a serum potassium level of 4.8 mEq/L. 4. The client who has a serum sodium level of 137 mEq/L.

4 Botulism is the most serious type of food poisoning and the client is exhibiting signs/symptoms of it; therefore, the nurse should return this phone call first.

The clinic nurse is triaging client's telephone calls. Which client should the nurse call first? 1. The client diagnosed with AIDS who has developed Kaposi's sarcoma. 2. The client diagnosed with dementia who is having difficulty dressing himself. 3. The client with trigeminal neuralgia who is having lightening-like shock to the cheeks. 4. The client whose friend has botulism who has vomiting and abdominal cramping pain.

3 Every hospital has a procedure for termination if the employee is not performing as expected. After two verbal warnings, the clinical manager should document the employee's actions in writing and implement the hospital policy for possible termination.

The clinical manager has verbally warned a female staff nurse about being late to work on two previous occasions. The nurse was 35 minutes late for today's shift. Which action should the charge nurse take? 1. Ask the staff nurse why she was late again today. 2. Notify the human resources department in writing. 3. Initiate the hospital policy for unacceptable behavior. 4. Do not allow the staff nurse to work on the unit today.

4 Democratic managers are people oriented and emphasize efficient group functioning. The environment is open, and communication flows both ways. Meetings to discuss concerns illustrate a democratic leadership style.

The clinical nurse manager on the endocrine unit overhears the staff nurses upset and arguing over how the clients are being assigned by the charge nurse. Which statement indicates a democratic leadership style by the clinical nurse manager? 1. "My charge nurse makes the assignments and I support how she does it." 2. "As long as there are no complaints from the clients I will not interfere." 3. "I appreciate you telling me about the situation and I will handle it." 4. "I will schedule a meeting and we will all sit down and discuss the situation."

4 This client should be categorized as black, priority 4, which means the injury is extensive and chances of survival are unlikely even with definitive care. Clients should receive comfort measures and be separated from other casualties, but not abandoned.

The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4? 1. The client who is alert and has a sucking chest wound. 2. The client who cannot stop crying and can't answer questions. 3. The client whose abdomen is hard and tender to the touch. 4. The client who has full thickness burns over 60% of the body.

2 An incompetent client cannot sign the consent form. An incompetent client is an individual who is not autonomous and cannot give or withhold consent, for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. The client may be able to sign the permit, but the nurse should question the client's ability to sign the permit because paranoid schizophrenia is a mental illness.

The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form? 1. The 16-year-old married client who is diagnosed with an ectopic pregnancy. 2. The 39-year-old client diagnosed with paranoid schizophrenia. 3. The 50-year-old client who admits to being a recovering alcoholic. 4. The 84-year-old client diagnosed with chronic obstructive pulmonary disease (COPD).

2 The nurse should suspect the client has a pulmonary embolus, a complication of the thrombophlebitis. Pulmonary emboli decrease the oxygen supply to the body, and the nurse should immediately administer oxygen to the client.

The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first? 1. Ask the HCP to order a stat lung scan. 2. Place oxygen on the client via nasal cannula. 3. Prepare to administer intravenous heparin. 4. Tell the client not to ambulate and remain in bed.

4 Fosamax should be administered on an empty stomach with a full glass of waterto promote absorption of the medication. The client should remain upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion.

The elderly female client diagnosed with osteoporosis is prescribed the bisphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication? 1. Administer the medication first thing in the morning. 2. Ask the client whether she has a history of peptic ulcer disease. 3. Encourage the client to walk for at least 30 minutes. 4. Have the client remain upright for 30 minutes after administering the medication.

3 Vaginal lubricant will help with the vaginal dryness and help decrease pain during sexual intercourse.

The elderly female client tells the nurse, "I have vaginal dryness and it hurts when my husband and I make love." Which priority intervention should the nurse discuss with the client? 1. Tell the client to discuss hormone replacement therapy with her HCP. 2. Encourage the client to refrain from having sexual intercourse. 3. Recommend the client use a vaginal lubricant prior to intercourse. 4. Explain to the client that vaginal dryness is not uncommon in the elderly.

1 This client would benefit from a home healthcare nurse's evaluation of the client's home and the wife's ability to care for the client.

The elderly wife of a client with a total hip replacement who is being discharged home tells the nurse, "I am really worried about taking my husband home. I don't know how I will be able to take care of him." Which intervention is most appropriate for the nurse? 1. Refer the client to the home health nurse. 2. Discuss the possibility of placing her husband in a nursing home. 3. Request the client's healthcare provider to talk to the wife. 4. Allow the client's wife to ventilate her feelings about the situation.

2 The urine specimen must adhere to a chain of custody, so the client cannot dispute the results.

The employee health nurse is obtaining a urine specimen for a pre-employment drug screen. Which action should the nurse implement first? 1. Obtain informed consent for the procedure. 2. Maintain the chain of custody for the specimen. 3. Allow the client to go to any bathroom in the clinic. 4. Take and record the client's tympanic temperature.

4 Antibiotic therapy is the priority intervention for the client with a diagnosed UTI. None of the health promotion activities will treat the UTI, though they will help prevent further UTIs.

The female client diagnosed with type 2 diabetes has frequent urinary tract infections (UTIs). Which priority intervention should the nurse implement? 1. Encourage the client to empty her bladder regularly and completely. 2. Instruct the client to drink 8 ounces of cranberry or lingonberry juice a day. 3. Explain the importance of taking oral hypoglycemic medications. 4. Discuss the importance of taking all the antibiotics.

3 An x-ray should not be completed on a client who may be pregnant. The x-rays could harm the fetus.

The female client with renal calculi is scheduled for a STAT kidney, ureter, bladder (KUB). Which statement by the client warrants intervention by the nurse? 1. "I am allergic to shell fish and iodine." 2. "I just had my lunch tray and ate all of it." 3. "I have not had my period for 3 months." 4. "I am having pain in my lower back."

2 Men often see the world from a logical perspective and focus on a specific intervention.

The female nurse manager is discussing the yearly performance evaluation with a male nurse. Which information regarding communication styles should the nurse manager employ when talking with the employee? 1. Men tend to see the work from a global perspective centering on feelings. 2. Men often see the work environment from a logical, focused perspective. 3. Men ask many more questions than women and require specific answers. 4. Men and women communicate similarly in a nursing environment.

4 This is the role of the physical therapist, a member of the home care team.

The home health (HH) aide caring for the client who is postoperative kidney trans- plant asks the home health nurse, "Why is the physical therapist coming to visit the client?" Which statement is the home health nurse's best response? 1. "The physical therapist will evaluate the client's swallowing difficulty." 2. "The physical therapist will assist the client with fine motor coordination." 3. "The physical therapist will assist with caregiver concerns and making referrals." 4. "The physical therapist will work with the client on strengthening and endurance."

2 This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service.

The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse's best response? 1. "I am so excited for you; he seems like a very nice young man." 2. "You should not go out with him as long as she is a client of our agency." 3. "I think you should tell the director of the HH care agency about this date." 4. "You should never date someone you meet while taking care of a client."

2 Saw palmetto is recommended by many urologists and used to treat BPH; therefore, this is the most appropriate statement.

The home health (HH) aide tells the home health nurse one of the older male clients is taking an herbal supplement, saw palmetto, every day. Which statement is the nurse's best response? 1. "Herbal supplements are dangerous and I will talk to the client." 2. "Saw palmetto is used to treat benign prostatic hypertrophy. Let him take it." 3. "I will notify the client's healthcare provider as soon as possible." 4. "Many clients use herbal supplements. He has a right to take it."

4 The physical therapist is the member of the healthcare team who is responsible for helping the client with mobility issues.

The home health (HH) aide tells the nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. Which intervention should the nurse implement? 1. Ask the HH aide whether the bathroom has grab bars. 2. Assess the client's ability to transfer in the home. 3. Instruct the HH aide to give the client a bed bath. 4. Contact the agency physical therapist about the situation.

4 The number 1 risk factor for a CVA is arterial hypertension. Because the client has a history of a CVA and is complaining of a severe headache, which is a symptom of hypertension, the nurse should first take the client's blood pressure. If it is elevated, the client needs to be taken to the emergency department. In the home setting, asking about the pain scale would not affect the care the nurse provides.

The home health (HH) nurse enters the home of an 80-year-old female client who had a cerebrovascular accident (CVA), or "brain attack," 2 months ago. The client is com- plaining of a severe headache. Which intervention should the nurse implement first? 1. Determine what medication the client has taken. 2. Assess the client's pain on a pain scale of 1 to 10. 3. Ask whether the client has any acetaminophen (Tylenol). 4. Tell the client to sit down, and take her blood pressure.

1 The nurse should first take care of the bite and then determine whether the dog is up to date on the required vaccinations. The nurse should be concerned about the possibility of rabies.

The home health (HH) nurse enters the yard of a client and is bitten on the leg by the client's dog. Which intervention should the nurse implement first? 1. Clean the dog bite with soap and water and apply antibiotic ointment. 2. Obtain the phone number and contact the client's veterinarian. 3. Contact the HH care agency and complete an occurrence report. 4. Ask the client whether the dog has had all the required vaccinations.

1, 2, and 3 are correct. 1. The HHA is capable of weighing a client and documenting the finding. 2. An HHA can offer the SO time away from the home to do personal business. 3. This is within the HHA's capabilities.

The home health (HH) nurse has arranged for a home health aide (HHA) to assist a 79-year-old client diagnosed with Alzheimer's disease. Which interventions should the nurse delegate to the HHA? Select all that apply. 1. Weigh the client once a week and document the weight on the patient record. 2. Stay with the client twice a week while the significant other(SO) goes out to run errands. 3. Take and record the client's vital signs. 4. Take the client to the bank and store to perform personal business. 5. Listen to the client's heart sounds and notify the HCP if abnormal sounds are heard.

2 The therapeutic value for INR is 2 to 3; levels higher than that increase the risk of bleeding. The nurse should first contact the client and determine whether she has any abnormal bleeding and then instruct the client to not take any more Coumadin.

The home health (HH) nurse in the office is notified the female client on warfarin (Coumadin), an oral anticoagulant, has an International Normalized Ratio (INR) of 3.8. Which action should the HH nurse implement first? 1. Document the result of the INR in the client's chart. 2. Contact the client and ask whether or not she has any abnormal bleeding. 3. Notify the client's healthcare provider of the INR results. 4. Schedule an appointment with the client to draw another INR.

1 The NCSBN NCLEX-RN® test blue- print includes referrals, under Management of Care. The client is in spiritual distress, and the chaplain is the member of the team who addresses spiritual needs.

The home health (HH) nurse is admitting a female client diagnosed with end-stage renal disease who refuses to be placed on hemodialysis. The client is ready to die, but verbalizes having so many regrets in her life. Which intervention would be most appropriate for the nurse? 1. Contact the agency chaplain to come talk to the client. 2. Call her church pastor and discuss the client's concerns. 3. Ask the client whether or not she would like to pray with the nurse. 4. Determine whether or not the client has an advance directive.

2 The priority intervention for the client with arterial hypertension is to take antihypertensive medications.

The home health (HH) nurse is caring for a client with arterial hypertension who has had a cerebrovascular accident. Which priority intervention should the nurse discuss with the client when teaching about arterial hypertension? 1. Discuss the importance of the client adhering to a low-salt diet. 2. Explain the need for the client to take antihypertensive medications as prescribed. 3. Tell the client to check and record their blood pressure readings daily. 4. Encourage the client to walk at least 30 minutes three times a week.

2 The home health aide is responsible for assisting the client with activities of daily living and transferring from the bed to the chair. Sitting outside is good for the client and is a task that can be delegated to the home health aide.

The home health (HH) nurse is caring for an elderly client. Which nursing task should the nurse delegate to the HH aide? 1. Cook and freeze meals for the client. 2. Assist the client to sit on the front porch. 3. Take the client for outings to the store. 4. Monitor the client's mental status.

3 Cardiac rehabilitation includes progressive exercise, diet teaching, and classes on modifying risk factors. This supervised setting would be the priority intervention for this client when the client is discharged from HH.

The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement? 1. Encourage the client to walk 30 minutes a day. 2. Request an HH-registered dietician to talk to the client. 3. Refer the client to a cardiac rehabilitation unit. 4. Discuss the client's need to lose 1 to 2 pounds a week.

2 The first intervention is to empty the client's bladder prior to the procedure.

A client has been diagnosed with rule out bacterial meningitis, and a nurse is assisting the healthcare provider with a lumbar puncture. Which intervention should the nurse implement first? 1. Have the client lie in the lateral recumbent position. 2. Tell the client to empty the bladder. 3. Encourage the client to complete an advance directive. 4. Keep the client NPO prior to the procedure.

3 The nurse should make sure that the client does not have any medical device implanted that could react with the magnetic field created by the MRI scanner. An implanted ECG device could prevent the client from having an MRI, depending on the age of the pacemaker and the material with which it was made.

An elderly client diagnosed with thyroid cancer frequently makes statements that are inappropriate for the situation, and is not oriented to place, time, or date. The HCP has ordered a magnetic resonance imaging (MRI) scan of the client's brain. Which intervention should the nurse implement? 1. Administer a mild sedative to prevent claustrophobia. 2. Order a vest restraint for use by the client during the MRI. 3. Make sure the client does not have a pacemaker. 4. Ask a family member to stay with the client while the test is performed.

4 This is a very high blood glucose level, and the client diagnosed with type 1 diabetes will be catabolizing fats at this level and is at risk for diabetic ketoacidosis (DKA) coma.

For which client's laboratory data should the charge nurse notify the HCP? 1. The potassium level of 3.6 mEq/L in a client diagnosed with heart failure who is taking the loop diuretic furosemide (Lasix). 2. The PTT level of 78 in the client diagnosed with pulmonary embolism who is receiving IV heparin. 3. The blood urea nitrogen (BUN) of 84 mg/dL in a client diagnosed with end-stage renal disease (ESRD) and peripheral edema. 4. The blood glucose level of 543 mg/dL in a client diagnosed with uncontrolled diabetes mellitus type 1.

1, 3, and 4 are correct. The UAP can make hourly rounds on the client, taking the client to the bathroom, giving the client a drink of water, checking to make sure the client is not climbing out of bed, etc. This client is in rehab and should be stable so that the UAP can set up the tray or feed the patient. The UAP can clamp and unclamp an indwelling catheter in a rehab area. This is a non-invasive skill that can be taught to the UAP. It does not require judgment.

The 19-year-old client is in the rehabilitation unit following a traumatic brain injury. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Make safety rounds hourly. 2. Refer the client to a college and career counselor. 3. Assist the client with meals. 4. Clamp and unclamp the indwelling catheter every 2 hours. 5. Discuss discharge placement with the parents.

4 A client in a rehabilitation unit for a brain injury should not require IV medications. The nurse should question this order.

The 24-year-old client diagnosed with a traumatic brain injury is being transferred to a rehabilitation unit. Which healthcare provider order should the nurse question? 1. Physical therapy to work on lower extremity strength daily. 2. Occupational therapy to work on cognitive functioning bid. 3. A soft diet with mechanical ground meats and thickening agent in fluids. 4. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

1 The rehabilitation nurse must recognize and address sexual issues in order to promote feelings of self-worth that are essential to total rehabilitation. The age of the client should not matter, but this client is young; therefore, this is priority.

The 28-year-old male client who sustained traumatic bilateral amputations secondary to a motor vehicle accident (MVA) is being discharged home to live with his wife and 3-year-old son. Which priority psychosocial intervention should the rehabilitation nurse discuss with the client? 1. Ask the client whether he has any sexual concerns he needs to discuss. 2. Determine whether the home is safe for ambulating with prosthetic devices. 3. Discuss the procedure for obtaining a specially equipped car. 4. Explain the importance of getting psychological counseling.

Correct Answer: 4, 5, 2, 3, 14. Safety should be the primary concern of the nurse. A bedside commode will provide the client with an option that is easier to get to than walking to the bathroom and prevent the client from slipping on urine that may be dribbled. 5. The nurse needs to obtain a urine culture, so antibiotic therapy can be initiated. 2. This will help the client stay dry and not soil his or her clothes, as well as allowing some independence in ambulation in the room and hallways. 3.This will protect the bed and the client from soiling. 1. Providing frequent assistance with toileting will prevent the client from having incontinence.

The 88-year-old female client is complaining of urinary frequency and dribbling. Which nursing interventions should be implemented? Rank in order of performance. 1. Have the unlicensed assistive personnel (UAP) make "potty" rounds on the client every 2 hours. 2. Give the client perineal pads to place inside her underwear. 3. Place an absorbent pad on the client's bed. 4. Put a bedside commode at the client's bedside. 5. Instruct the client in providing a clean-catch urine specimen.

1 This statement warrants intervention because fluids will help prevent dehydration and renal calculi. The nurse should explain the client needs to increase fluids.

The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse? 1. "I do not give her a lot of fluids so she won't wet the bed." 2. "I perform passive range-of-motion exercises every morning." 3. "I put her on her side so that there will be no pressure on her butt." 4. "I do not pull her across the sheets when I am moving her in bed."

3 An incompetent client is an individual who is not autonomous and cannot give or withhold consent—for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. This client is diagnosed with schizophrenia, a mental illness, and is delusional; therefore, the client's significant other must sign for the procedure.

The HCP orders an intravenous pyelogram for the 27-year-old male client diagnosed with R/O renal calculi. The client is diagnosed with schizophrenia and is delusional. Which action should the clinic nurse implement? 1. Ask the client whether he is allergic to yeast. 2. Request the client to sign a permit for the procedure. 3. Obtain informed consent from the client's significant other. 4. Discuss the local hospital's day surgery procedure with the client.

3 This behavior may be cultural, and the nurse should continue to allow the husband to answer the questions, while the nurse looks at the client. The nurse must be respectful of the client's culture. The nurse can, however, ask whether the client agrees with the husband's answers.

The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take? 1. Ask the husband to allow his wife to answer the questions. 2. Request the husband to leave the examination room. 3. Continue to allow the husband to answer the wife's questions. 4. Do not ask any further questions until the client starts answering.

The nursing supervisor should intervene and listen to both staff members' concerns and attempt to help resolve the disagreement. This is the director's first intervention.

The Home Health Director of Nurses hears a nurse and the occupational therapist loudly disagreeing about the care of a newly admitted client while they are sitting in an area that is accessible to anyone coming into the office. Which action should the Director of Nurses implement first? 1. Ask the staff members to move the argument to another room. 2. Request both individuals to come into the director's office. 3. Call the secretary with instructions for the staff to quit arguing. 4. Tell the staff members that arguing is not allowed in the office.

1 The nurse should first assess the client's neurological status to determine the status of the client.

The LPN tells the nurse the client diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first? 1. Assess the client's neurological status. 2. Notify the client's healthcare provider. 3. Request a STAT ammonia serum level. 4. Tell the LPN to obtain the client's vital signs.

3 This is the best instruction for the nurse to give to the UAP.

The UAP enters the elderly female client's room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP? 1. Tell the UAP to complete the bath at this time. 2. Have the UAP skip the client's bath for the day. 3. Instruct the UAP to give the bath after the program. 4. Document the attempt to give the bath as refused.

3 The nurse should allow the UAP to continue to talk to the female student, and then the nurse can talk to the student after the UAP and student finish talking.

The UAP in the school nurse's office is listening to a female student who is pregnant and scared to tell her parents. Which action should the school nurse implement? 1. Tell the UAP she cannot talk to the female student. 2. Call the student's parents and tell them their daughter is pregnant. 3. Do not take any action and allow the UAP to listen to the student. 4. Ask the UAP to leave and continue to talk to the student.

2 The first action for the administrative supervisor is to make sure the clients receive care. The supervisor cannot allow the on-duty staff to leave until replacement staff members have been arranged.

The administrative supervisor is staffing the hospital's medical-surgical units during an ice storm and has received many calls from staff members who are unable to get to the hospital. Which action should the supervisor implement first? 1. Inform the chief nursing officer. 2. Notify the on-duty staff to stay. 3. Call staff members who live close to the facility. 4. Implement the emergency disaster protocol.

3 This client has signs of dehydration, which is not expected when a client is vomiting. The client should remain hydrated even when the client is vomiting.

The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with ulcerative colitis who had five loose stools the previous shift. 2. The elderly client admitted from another facility who is refusing to be seen by the nurse. 3. The client with intractable vomiting who has tented skin turgor and dry mucous membranes. 4. The client with hemorrhoids who had spotting of bright red blood on the toilet tissue.

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

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a stroke who has a platelet level of 250,000 μ/L. 2. The client with a seizure disorder who has a divalproex (Depakote) level of 75μg/mL. 3. The client with multiple sclerosis on prednisone who has a glucose level of 208mg/dL. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL.

3 The charge nurse should call a meeting and attempt to determine what is causing the staff's behavior and the tense atmosphere. The charge nurse could then problem-solve, with the goal being to have a more relaxed atmosphere in which to work.

The charge nurse in a large outpatient clinic notices the staff members are arguing and irritable with one other and the atmosphere has been very tense for the past week. Which action should the charge nurse take? 1. Wait for another week to see whether the situation resolves itself. 2. Write a memo telling all staff members to stop arguing. 3. Schedule a meeting with the staff to discuss the situation. 4. Tell the staff to stop arguing or they will be terminated.

3 The float nurse from the medical unit is able to administer antibiotic therapy and complete respiratory assessments; therefore, this client would be the most appropriate client to assign to the float nurse.

The charge nurse in the intensive care unit asks a nurse to float from the medical/ surgical unit to the ICU. Which client should the charge nurse assign to the float nurse? 1. The client who is 3 hours postoperative lung transplant. 2. The client who has a central venous pressure of 13 cm H2O. 3. The client who is diagnosed with bacterial pneumonia. 4. The client who is diagnosed with Hantavirus pulmonary syndrome.

2 The nurse should notify the supervisor that the nurse is concerned that the assignment will not allow the nurse to provide adequate care to any of the three clients. This is the first step the nurse should implement.

The charge nurse in the vascular intensive care unit assigns three clients to the staff nurse. The staff nurse thinks this is an unsafe assignment. Which action should the staff nurse implement first? 1. Refuse to take the assignment and leave the hospital immediately. 2. Tell the supervisor that he or she is concerned about the unsafe assignment. 3. Document his or her concerns in writing and give it to the supervisor. 4. Take the assignment for the shift but turn in his or her resignation.

4 The client diagnosed with hyperthyroidism should have a decreased TSH level; therefore, the nurse should notify the client's HCP.

The charge nurse is checking the morning laboratory results for the clients. Which laboratory results require notifying the client's healthcare provider? 1. The client with hypoparthyroidism who has a decreased serum calcium level. 2. The client with Cushing's disease who has a decreased urine cortisol level. 3. The client with diabetes insipidus who has a low urine specific gravity. 4. The client with hyperthyroidism who has an increased TSH level.

1 The most experienced nurse should be assigned to the client who requires teaching prior to being discharged. Postoperative complications can occur, so the client must be knowledgeable of when to call the healthcare provider and how to take care of the surgical site.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The 24-year-old client who had a circumcision and is being prepared for discharge. 2. The client scheduled for a cystectomy who is crying and upset about the surgery. 3. The client diagnosed with kidney cancer who is receiving two units of blood. 4. The client who has end-stage renal disease and had an arteriovenous fistula created.

2 This client is being prepared for a test in the morning and is the least acute of the clients listed. The new graduate should be assigned to this client.

The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received three units of packed red blood cells (RBCs). 2. The client scheduled for an esophagogastroduodenoscopy in the morning. 3. The client with short bowel syndrome who has diarrhea and a K+ level of 3.3mEq/L. 4. The client who has just returned from surgery for a sigmoid colostomy.

3 This client is exhibiting symptoms of asthma, a complication of GERD; therefore, the client should be assigned to the most experienced nurse.

The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with lower esophageal dysfunction who is experiencing regurgitation. 2. The client diagnosed with Barrett's esophagitis who is scheduled for an en- doscopy. 3. The client diagnosed with gastroesophageal reflux disease who has bilateral wheezes. 4. The client diagnosed with 1 day post-op hiatal hernia who has pain rated a 4 on a pain scale of 1 to 10.

1 Because the client is having an evolving stroke, the client is experiencing a worsening of signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

1 Although cystectomy is a major surgical procedure, it has a predictable course, and no complications were identified. After removing the bladder, the client must have an ileal conduit. This is expected with this type of surgery, and the new graduate nurse could be assigned of this client.

The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation? 1. The client with a cystectomy who had a creation of an ileal conduit. 2. The client on continuous hemodialysis who is awaiting a kidney transplant. 3. The client with renal trauma secondary to a motor vehicle accident. 4. The client who has had abdominal surgery and whose wound has eviscerated.

3 The UAP can change a sharps container. This must be done because a sharps container above the fill line is a violation of Occupational Safety Health Administration (OSHA) rules and can result in a financial fine.

The charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. Which action should the charge nurse implement? 1. Complete an adverse occurrence report. 2. Discuss the situation with the primary nurse. 3. Instruct the UAP to change the sharps container. 4. Notify the infection control nurse immediately.

3 It is within an LPN's scope of practice to change an ileal conduit drainage bag; therefore, this would be the most appropriate assignment for the LPN.

The charge nurse is making shift assignments to the surgical staff, which consists of two nurses, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAP). Which assignment would be most appropriate for the charge nurse to make? 1. Instruct the nurse to administer all PRN medications. 2. Instruct the UAP to clean the recently vacated room. 3. Assign the LPN to change the client's ileal conduit bag. 4. Request the LPN to complete the admission for a new client.

1 Because a client undergoing an elective procedure such as a gastric lap banding is usually healthy prior to the surgery, an elevated postoperative WBC count—which this client has—may indicate infection and, therefore, requires notifying the HCP.

The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone? 1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm. 2. The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36. 3. The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL. 4. The client who is 8 hours postoperative for exploratory laparotomy who has a serum potassium level of 4.5 mEq/L.

2 The client must be NPO for 8 to 10 hours before the procedure. Therefore, the dietary department should be notifiedto hold the meal trays.

The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure? 1. The cardiac catheterization department. 2. The dietary department. 3. The nuclear medicine department. 4. The hospital laboratory department.

2 The charge nurse should not reprimand the nurse in front of the client or client's family. The charge nurse should ask the nurse to step into the hall, where the client cannot hear.

The charge nurse notices a nurse recapping a needle in a client's room. Which action should the charge nurse take first? 1. Tell the nurse not to recap the needle. 2. Quietly ask the nurse to step into the hall. 3. Reprimand the nurse for not following procedure. 4. Notify the house supervisor of the nurse's behavior.

1 This question will determine whether the nurse has assessed the client's ability to swallow. The nurse cannot delegate unstable clients, and a client newly diagnosed with a CVA may be unstable and have difficulty swallowing.

The charge nurse observes the client's nurse telling the unlicensed assistive personnel (UAP) to feed an elderly client diagnosed with a cerebrovascular accident (CVA). Which question should the charge nurse ask the client's nurse? 1. "How does the client swallow the medications?" 2. "Did you complete your head to toe assessment?" 3. "Does the client have some Thick-It in the room?" 4. "Why would you delegate feeding to a UAP?"

1 The charge nurse will not always be available to intercede for the new graduate. The charge nurse should wait and see whether the new graduate is capable of handling the situation before intervening.

The charge nurse observes the new graduate nurse delegating tasks to the unlicensed assistive personnel (UAP) and the UAP appears to be ignoring the graduate nurse. Which action should the charge nurse implement first? 1. Wait and observe how the graduate nurse handles the situation. 2. Tell the UAP to get busy and complete the assigned tasks. 3. Discuss learning to assert authority with the new graduate. 4. Informally counsel the UAP about the response to the nurse.

2 Hospital personnel are not immune to human emotions. The UAP needs a short time to compose him- or herself. The nurse should offer the UAP compassion. If this occurred with every death, the UAP could be counselled to transfer to a different area of the hospital.

The charge nurse observes the unlicensed assistive personnel (UAP) crying after the death of a client. Which is the charge nurse's best response to the UAP? 1. "If you cry every time a client dies, you won't last long on the unit." 2. "It can be difficult when a client dies. Would you like to take a break?" 3. "You need to stop crying and go on about your responsibilities." 4. "Did you not realize that clients die in a healthcare facility?

3 This client requires an experienced UAP who is skilled in client lifts, so the client is lifted safely and the UAP is not injured in the process. The most experienced UAP should be assigned this client.

The charge nurse of a long-term care facility is making assignments. Which client should be assigned to the most experienced unlicensed assistive personnel (UAP)? 1. The client with arterial occlusive disease who must dangle the legs off the side of the bed. 2. The client with congestive heart failure who is angry about the family not visiting. 3. The client with an above the knee amputation who needs a full body lift to get in the wheelchair. 4. The client with Buerger's disease who is particular about the way things are done.

2 This client is stable and could be prescribed oral pain medication. She could be discharged home and followed by home health nursing if needed. This client is the most appropriate client for the charge nurse to request to be discharged.

The charge nurse of a surgical unit has been notified of an external disaster with multiple casualties. Which client should the charge nurse request to be discharged from the hospital to make room for clients from the disaster? 1. The client scheduled for a bilateral adrenalectomy in the morning whose preoperative teaching has not been started. 2. The client who had a total abdominal hysterectomy 2 days ago and PCA machine has been discontinued. 3. The client who is postoperative bilateral thyroidectomy who has a hemoglobin of 7 mg/dL and a hematocrit of 22.1%. 4. The client with type 2 diabetes who has just had a kidney transplant and is experiencing fever and pain at the surgical site.

3, 5 This client's status is uncertain. The ICU nurse would be an appropriate assignment for this client since the patient will be moved to ICU soon. The intensive care nurse should care for this client requiring titration of multiple medications simultaneously.

The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select the patient/patients that apply. 1. The client who had four coronary artery bypass grafts 3 days ago. 2. The client who has anterior and posterior chest tubes after a motor vehicle accident. 3. The client who will be moved to the intensive care unit when a bed is available. 4. The client who has a do not resuscitate order and is requesting to see a chaplain. 5. The client who is on multiple intravenous drip medications needed to be titrated.

3 The LPN with maternal child area experience would be most helpful to the nursery.

The charge nurse on a busy 20-bed endocrinology unit must send one staff member to the nursery. Which staff member is most appropriate to send to the nursery? 1. The nurse who has worked on the endocrinology unit for 4 years. 2. The graduate nurse who has been on the endocrinology unit for 6 months. 3. The licensed practical nurse (LPN) who has worked in a newborn nursery at another facility. 4. The unlicensed assistive personnel (UAP) who has six small children of her own.

3 Deep, unrelenting pain is a sign of compartment syndrome, an acute, potentially life-threatening complication, in a client with a fracture; therefore, this client should be assigned to the most experienced nurse.

The charge nurse on the acute care rehabilitation unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse? 1. The client with a full-thickness burn who is refusing to go to therapy. 2. The client with osteomyelitis who has bone pain and a fever. 3. The client with fractured tibia who has deep, unrelenting pain. 4. The client with low back pain radiating down the left leg.

4 The RN with medical unit experience would be the most appropriate nurse to send to the emergency department because this nurse has experience that would be helpful in the ED. The nurse is also an RN, who would be more helpful in the ED than a UAP or an LPN.

The charge nurse on the busy 36-bed rehabilitation unit must send one staff member to the emergency department (ED). Which staff member is the most appropriate person to send? 1. The LPN who has worked on the rehabilitation unit for 3 years. 2. The RN who has been employed on the rehabilitation unit for 8 years. 3. The UAP who is completing the 4-week orientation to the rehabilitation unit. 4. The RN who transferred to the rehabilitation unit from the medical unit.

2 This is a win-win strategy that focuses on goals and attempts to meet the needs of both parties. The charge nurse keeps an experienced nurse and the staff nurse keeps her position. Both parties win.

The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy? 1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit. 2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift. 3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated. 4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team.

3 The ABG shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature.

The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.

4 The LPN can perform a sterile procedure such as completing an in and out catheterization.

The charge nurse on the endocrine surgical unit is making assignments. Which task should be delegated/assigned to the team members? 1. Request the licensed practical nurse (LPN) assess the client who is hypoglycemic. 2. Ask the unlicensed assistive personnel (UAP) to assist feeding the client with an adrenalectomy who has a paralytic ileus. 3. Instruct the UAP to insert a nasogastric (N/G) tube into the client who has had a thyroidectomy. 4. Tell the LPN to perform an in and out catheterization for the client diagnosed with acromegaly.

1 The residual limb of an AKA should be elevated after 48 hours to help prevent contractures. Since the client is in the rehabilitation unit, it is past 48 hours.

The charge nurse on the rehabilitation unit is assigning/delegating tasks to the unlicensed assistive personnel (UAP) and licensed practical nurse (LPN). Which task is most appropriate for the nurse to delegate/assign? 1. Tell the UAP to elevate client's residual limb above the heart. 2. Instruct the LPN to give the diabetic clients their HS snacks. 3. Request the UAP to insert an indwelling urinary catheter. 4. Ask the LPN to assess the client who may have herpes zoster.

1 The LPN's scope of practice allows the LPN to take telephone orders.

The charge nurse on the rehabilitation unit is making assignments for the day shift. Which assignment would be most appropriate for the licensed practical nurse (LPN)? 1. Have the LPN call the HCP to obtain an order for a diet change. 2. Instruct the LPN to complete the admission assessment. 3. Ask the LPN to teach the client about a high-fiber diet. 4. Request the LPN to obtain the intake and output for the clients.

3 Most disaster policies require one nurse to be sent immediately from each area; therefore, this intervention should be implemented first. The charge nurse must determine which staff nurse would be most helpful in the ED without compromising the staffing in the ICU.

The charge nurse on the renal unit is notified of a bus accident with multiple injuries and clients are being brought to the emergency department (ED). The hospital is implementing the disaster policy. Which action should the nurse take first? 1. Determine which clients could be discharged home immediately. 2. Call any off-duty nurses to notify them to come in to work. 3. Assess the staffing to determine which staff could be sent to ED. 4. Request all visitors to leave the hospital as soon as possible.

3 Antibiotic therapy can result in a superinfection that destroys the normal bacterial flora of the intestines and produces diarrhea. Diarrhea, in turn, causes an increased excretion of potassium, resulting in hypokalemia. This K+ level is below normal, and the charge nurse should notify the healthcare provider.

The charge nurse received laboratory data on the following clients. Which client warrants immediate intervention by the charge nurse? 1. The client with COPD who has ABGs of pH, 7.35; PaO2, 77; PaCO2, 57; HCO3, 24. 2. The client diagnosed with bilateral TKR who has a WBC count of 10,400. 3. The client on antibiotic therapy who has a serum potassium level of 3.3 mEq/L. 4. The client receiving TPN who has a glucose level of 145 mg/dL.

2 The LPN can apply medication to the client's athlete's foot; therefore, this is an appropriate assignment for the LPN.

The charge nurse, a licensed practical nurse (LPN), and two unlicensed assistive personnel (UAPs) are caring for clients. Which action is most appropriate for the charge nurse to assign/delegate? 1. Ask the UAP to apply warm compresses to the client with tinea corporis. 2. Request the LPN to apply antifungal cream to the client with tinea pedis. 3. Tell the UAP to remove the toenail of the client with onychomycosis. 4. Instruct the LPN to administer accutane to the client who is pregnant.

1 Evisceration is the removal of viscera (internal organs, especially those in the abdominal cavity). If the bowels protrude from the abdominal incision, the nurse must apply sterile normal saline gauze and then notify the client's surgeon.

The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? 1. Place sterile normal saline gauze on the eviscerated area. 2. Reinforce the abdominal dressing with an ABD pad. 3. Assess the client's abdominal bowel sounds. 4. Place the client in the left lateral position.

1 During a laparoscopic cholecystectomy, carbon dioxide is instilled into the client's abdomen. Postoperatively, the gas migrates to the shoulder by gravity and causes shoulder pain.

The client 2 days postoperative from a laparoscopic cholecystectomy tells the office nurse, "My right shoulder hurts so bad I can't stand it." Which statement is the nurse's best response? 1. "This is a result of the carbon dioxide gas used in surgery." 2. "Call 911 and go to the emergency department immediately." 3. "Increase the pain medication the surgeon ordered." 4. "You need to ambulate in the hall to walk off the gas pains."

2 The nurse should first inform the HCP so the order can be written in the client's chart. The HCP must write the do not resuscitate (DNR) order before the client's wishes can be honored.

The client admitted to the critical care unit tells the nurse, "I have an advance directive (AD) and I do not want to have cardiopulmonary resuscitation (CPR)." Which intervention should the nurse implement first? 1. Ask the client for a copy of the AD so that it can be placed in the chart. 2. Inform the healthcare provider of the client's request as soon as possible. 3. Determine whether the client has a durable power of attorney for healthcare. 4. Request the hospital chaplain to come and talk to the client about this request.

3 The nurse must first determine whether the client has any injuries before taking any other action. This is the first intervention the nurse must implement prior to moving the client.

The client ambulating down the orthopedic hallway unassisted fell to the floor. Which action should the nurse implement first? 1. Complete an adverse occurrence report. 2. Notify the clinical manager on the unit. 3. Determine whether the client has any injuries. 4. Ask why the client was in the hall alone.

3 Influenza, or flu, is a serious respiratory illness. It is easily spread from person to person and can lead to severe complications, even death. The best way to prevent the influenza is to get a flu vaccine every year. The influenza virus is constantly changing. Each year, scientists work together to identify the virus strains that they believe will cause the most illness, and a new vaccine is made based on their recommendations.

The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?" Which statement is the nurse's best response? 1. "Take prophylactic antibiotics for 10 days after being exposed to influenza." 2. "Stay away for large crowds and wear a scarf over your mouth during cold weather." 3. "The best way to prevent getting influenza is to get a yearly flu vaccine." 4. "You must eat three well-balanced meals a day and exercise daily to prevent influenza.

3 The client is verbalizing the classic signs/symptoms of a urinary tract infection, but it must be confirmed with a urinalysis. The nurse should first obtain the specimen so the results will be available by the time the HCP sees the client.

The client comes to the clinic reporting pain and burning on urination. Which action should the nurse implement first? 1. Assess and document the client's vital signs. 2. Determine whether the client has seen any blood in the urine. 3. Request the client give a midstream urine specimen. 4. Ask the client whether she wipes front to back after a bowel movement.

1 Chest pain on deep inspiration is a symptom of pulmonary embolism. The nurse should first place the client on oxygen.

The client complains of chest pain on deep inspiration. Which intervention should the nurse implement first? 1. Place the client on oxygen. 2. Assess the client's lungs. 3. Notify the respiratory therapist. 4. Assess the client's pulse oximeter reading.

4 This document would be most appropriate for the nurse to recommend because it names an individual to be responsible in the event the client cannot make healthcare decisions for himself or herself.

The client diagnosed with Addison's disease is being prepared for emergency surgery and is asking to complete an advance directive. Which type of advance directive should the nurse recommend the client complete at this time? 1. Power of attorney. 2. Living will. 3. Do not resuscitate (DNR) order. 4. Durable power of attorney for healthcare.

1 This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home healthcare or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time.

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center.

3 All clients remaining in a wheelchair for extended periods of time should have a wheelchair cushion that relieves pressure to prevent skin breakdown.

The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? 1. Encourage the client to move the buttocks every 2 hours. 2. Order a high-protein diet to prevent skin breakdown. 3. Get a pressure-relieving cushion to place in the wheelchair. 4. Refer the client to physical therapy for transfer teaching.

1 The physical therapist addresses crutch walking, how to use a walker, gait training, or transferring techniques. This is the most appropriate team member to address the problem.

The client diagnosed with a fractured right ankle needs to be instructed on crutch walking. Which member of the multidisciplinary team should address this problem? 1. The physical therapist. 2. The social worker. 3. The occupational therapist. 4. The rehabilitation physician.

1, 2, 3, and 4 are correct. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should be referred to occupational therapy for assistance with per- forming activities of daily living (ADLs). The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. These exercises should be done atleast five times a day for 10 minutes at a time to help strengthen the muscles used for walking.

The client diagnosed with a right-sided cerebral vascular accident (CVA), or brain attack, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Refer the client to occupational therapy daily. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises five times a day. 5. Instruct the client to hold the fingers in a fist.

3 The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the N/G tube. Therefore, the nurse should check the N/G wall suction.

The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs? 1. Assess the client to rule out any complications secondary to the client's pain. 2. Determine the last time the client was medicated for abdominal pain. 3. Check the amount of suction on the client's nasogastric tube. 4. Administer intravenous sodium bicarbonate to the client.

2 The client with active TB must take the medication as prescribed for 9-12 months. If the client refuses to take the medication, a court order will be obtained to make the client take the medication because tuberculosis is a community threat.

The client diagnosed with active tuberculosis tells the public health nurse, "I am not going to take any more medications. I am tired of them." Which statement is the nurse's best response? 1. "You are tired of taking your tuberculosis medications." 2. "You must take your TB medications. It is not an option." 3. "You must discuss this with your healthcare provider." 4. "As long as you wear a mask, you do not have to take the meds."

1 Acute respiratory distress syndrome is diagnosed when the client has an arterial blood gas of less than 50% while receiving oxygen at 10 LPM. The nurse should prepare for the client to be intubated.

The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first? 1. Prepare the client for intubation. 2. Bag the client with a bag/mask device. 3. Call a Code Blue and initiate cardiopulmonary resuscitation (CPR). 4. Start an IV with an 18-gauge catheter.

2 This response allows the family/ significant other to know there has been some incident, but it does not disclose the death. This is the best statement for the nurse at this time. The family will be able to arrive safely at the hospital before hearing the news their loved one has died.

The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse must notify the significant other. Which statement made by the nurse is the best over the telephone? 1. "I am sorry to tell you, but your loved one has died." 2. "Could you come to the hospital? The client is not doing well." 3. "The HCP has asked me to tell you of your family member's death." 4. "Do you know whether the client wished to be an organ donor?"

3 and 5 are correct. 3. All urine for 24 hours should be saved and put in a container with a preservative, refrigerated, or put on ice, as indicated. Not following specific instructions will result in an inaccurate test result. 5. Posting signs will help ensure that all the urine is saved during the 24-hour period. If any urine is discarded, the test may result in inaccurate information or the need to start the test over.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Keep the client NPO during the time the urine is being collected. 2. Instruct the client to urinate, and include this urine when starting collection. 3. Place client's urine in an appropriate specimen container for 24 hours. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Post signs on the client's door alerting staff to save all of the client's urine output.

3 The only way to tell for sure if a skin growth is cancerous is to biopsy it.

The client has an area on the skin the dermatologist thinks may be basal cell carcinoma. Which intervention will the nurse implement to confirm the diagnosis? 1. Refer the client for the magnetic resonance imaging (MRI). 2. Explain how to obtain a washing of the abnormal skin area. 3. Prepare the client for a biopsy of the abnormal skin growth. 4. Tell the client there is no way to definitively confirm the diagnosis.

1 The client's PaO2 is below the normal level of 80-100; therefore, the nurse should administer oxygen.

The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement? 1. Administer oxygen 6 L/min via nasal cannula. 2. Encourage the client to take deep breaths. 3. Administer intravenous sodium bicarbonate. 4. Assess the client's respiratory status.

Correct Answer: 2, 1, 4, 5, 3 2. The client has signs of phlebitis and the IV must be removed to prevent further complications. 1. A new IV will be started in the right hand after the IV is discontinued. 4. A warm washcloth placed on an IV site sometimes provides comfort to the client. If this is done, it should be done for 20 minutes four times a day. 5. All pertinent situations should be documented in the client's chart. 3. Depending on the healthcare facility, this may or may not be done, but client care comes before documentation.

The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation, it is edematous, and a red streak has formed. Which interventions should the nurse implement? Rank in priority order. 1. Start a new IV in the right hand. 2. Discontinue the intravenous line. 3. Complete an incident record. 4. Place a warm washcloth over the site. 5. Document the situation in the client's chart.

2 This statement will allow the client to ventilate feelings of helplessness and fear. It is the nurse's best response.

The client in a motor vehicle accident (MVA) is in critical condition with a pelvic fracture, flail chest, bilateral arm fractures, and a left hip fracture. The client tells the nurse, "I just want to die. I can't feed myself or clean myself." Which statement is the nurse's best response? 1. "I know this must be hard for you but you can have a life." 2. "I can see you must feel helpless; I am here to listen." 3. "Have you thought about killing yourself?" 4. "You are in shock but in time things will get better."

4 The nurse must stop everything and clarify which leg will have the surgical procedure. This is the first and priority intervention the nurse must implement.

The client in the day surgical unit is scheduled to have vein ligation on the right leg. The client states, "I am having surgery on my left leg." Which intervention should the nurse implement first? 1. Have the client sign the surgical operative permit. 2. Assess the client's neurological status. 3. Ask when the client last took a drink of water or ate anything. 4. Call a time out until clarifying which leg is having the vein ligation.

4 A client who has been intubated for10 to 14 days and still requires mechanical ventilation should have a surgically placed tracheostomy to prevent permanent vocal cord damage.

The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next? 1. Transfer to a long-term care facility. 2. Daily arterial blood gases. 3. Removal of life support. 4. Placement of a tracheostomy.

1, 3, 4, and 5 are correct. 1. There must be a manual resuscitation bag at the bedside in case the ventilator does not work appropriately. The nurse must use this to bag the client. The client's respiratory status should be assessed frequently—every 2 hours. The ventilator's settings should be monitored throughout the shift. The respiratory therapist is the member of the multidisciplinary team who is responsible for ventilators.

The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Ensure there is a manual resuscitation bag at the bedside. 2. Monitor the client's pulse oximeter reading every shift. 3. Assess the client's respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist.

3 The client is exhibiting signs/symptoms of hypopharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage.

The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client's oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation.

3 Finding ways for the client to perform the exercises by the physical therapist is supporting the medical regimen. This action supports client advocacy. PTs cannot prescribe.

The client in the rehabilitation unit tells the nurse, "I will not go to physical therapy again because it hurts so much when I do the exercises." Which statement supports the nurse's role as a client advocate? 1. "You do not have to go to physical therapy if it causes you pain." 2. "I will talk to the physical therapist (PT) about the exercises that cause you pain." 3. "Let me check and see if you can receive pain medication before therapy." 4. "I will discuss your concerns at the next multidisciplinary team meeting."

1 Nonmalfeasance means to do no harm. This statement is letting the client know that the concern has been heard but does not give the client bad news before surgery. The nurse is aware that someone having surgery should be of sound mind, and finding out your child is dead would be horrific.

The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmalfeasance? 1. "I will find out for you and let you know after surgery." 2. "I am sorry but your child died at the scene of the accident." 3. "You should concentrate on your surgery right now." 4. "You are concerned about your child. Would you like to talk?"

1 The unlicensed assistive personnel (UAP) cannot increase the irrigation fluid because this requires assessment and judgment. This behavior warrants intervention by the nurse.

The client is 1 day postoperative transurethral resection of the prostate (TURP). Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP increased the client's irrigation fluid to clear clots from the tubing. 2. The UAP elevated the client's scrotum on a towel roll for support. 3. The UAP emptied the client's indwelling urinary catheter bag. 4. The UAP brought ice water to the client's bedside.

2 Logrolling clients when turning is essential and priority to maintain proper body alignment.

The client is 8 hours postoperative spinal surgery. Which priority intervention should the nurse implement? 1. Evaluate how much pain medication the client is using via the patient-controlled analgesia (PCA) pump. 2. Logroll the client with three staff members when turning the client side to side. 3. Assist the client to ambulate to the bathroom using an elevated commode seat. 4. Place pillows under the thighs of each leg when the client is in supine position.

3, 4, and 5 are correct. 3. The client is weighed daily in the same clothes and at the same time to monitor for fluid overload and evaluate daily weight. 4. The IV tubing is changed with every bag because the high glucose level can cause bacterial growth. 5. Intake and output are monitored to observe for fluid balance.

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. 1. Place the client's TPN on a gravity intravenous line. 2. Monitor the client's blood glucose every 24 hours. 3. Weigh the client daily, first thing in the morning. 4. Change the client's IV tubing with every TPN bag administered. 5. Monitor the client's intake and output every shift.

4 This statement supports the ethical principle of veracity, which is the duty to tell the truth. This statement will probably further upset the client and cause psychological distress, which may hinder the recovery period.

The client is admitted to the critical care unit after a motor vehicle accident. The client asks the nurse, "Do you know if the person in the other car is all right?" The nurse knows the person died. Which statement supports the ethical principle of veracity? 1. "I am not sure how the other person is doing." 2. "I will try to find out how the other person is doing." 3. "You should rest now and try not worry about it." 4. "I am sorry to have to tell you, but the person died."

2 The priority intervention in the first 24 hours for the client with a third degree burn is maintaining intravascular volume so the client will not die from hypovolemic shock.

The client is admitted to the emergency department (ED) with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? 1. Maintain sterile environment when caring for the client. 2. Insert two large-bore intravenous access routes. 3. Administer intravenous antibiotic therapy. 4. Assess the client's pain level on a 1 to 10 pain scale.

2 The client is exhibiting symptoms of shock. The nurse should start IV lines to prevent the client from progressing to circulatory collapse.

The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first? 1. Type and crossmatch the client for PRBCs. 2. Start two IVs with large-bore catheters. 3. Obtain the client's history and physical. 4. Check the client's allergies to medications.

3 In acute DI, hypotonic saline is administered intravenously and is titrated to replace urinary output. Restoring circulatory volume is the priority intervention. Remember Maslow's Hierarchy of Needs; physiological needs are priority.

The client is admitted to the endocrinology unit newly diagnosed with an acute exacerbation of central diabetes insipidus (DI). Which intervention is the priority nursing intervention? 1. Obtain the client's baseline weight. 2. Administer desmopressin acetate (DDAVP) intranasally. 3. Administer intravenous hypotonic saline. 4. Monitor the client's intake and output.

1 The primary nurse's instruction to the UAP to assist the client to the bathroom is an appropriate delegation that ensures the safety of the client. It requires no action by the charge nurse.

The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement? 1. Take no action because this is appropriate delegation. 2. Tell the UAP to obtain a bedside commode for the client. 3. Discuss the inappropriate delegation of the nursing task. 4. Document the situation in an adverse occurrence report.

1 The normal serum sodium level is 135-145 mEq/L; this sodium level is elevated, indicating the client is dehydrated, which warrants intervention by the nurse.

The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse? 1. A serum sodium level of 152 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 4.8 mEq/L. 4. A stool sample that is positive for fecal leukocytes.

1 It will take approximately 6 weeks for the wound to sufficiently heal prior to being fitted for a prosthetic eye.

The client is postoperative a right eye enucleation. Which statement indicates the client needs more discharge teaching? 1. "It will be approximately 2 weeks before I can get a prosthetic eye." 2. "I can show you how to insert the conformer in the socket in case it falls out." 3. "I should insert the eye drops into the lower conjunctiva of my eye." 4. "If I develop an increased temperature I should call my healthcare provider."

2 Answering the call lights of the other clients on the unit can be delegated to the UAP.

The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)? 1. Have the UAP call the operator and announce the code. 2. Tell the UAP to answer the other call lights on the unit. 3. Send the UAP to the room to start rescue breaths. 4. Ask the family to step out of the room during the code.

3 Normal saline infusion increases the amount of volume in the bloodstream, which will decrease the client's lightheadedness and dizziness.

The client receiving dialysis is complaining of being dizzy and light-headed. Which priority intervention should the nurse implement? 1. Place the client in the reverse Trendelenburg position. 2. Decrease the volume of blood being removed from the client. 3. Bolus the client 300 mL of 0.9% saline solution. 4. Notify the healthcare provider as soon as possible.

1 HIPAA does not apply in some situations, including the reporting of sexually transmitted diseases to the Public Health Department. The Public Health Department will attempt to notify any sexual partners the client reports.

The client scheduled for a D&C is upset because the HCP told her she has syphilis. The client asks the nurse, "This is so embarrassing. Do you have to tell anyone about this?" Which statement is the nurse's best response? 1. "This must be reported to the Public Health Department and your sexual partners." 2. "According to the Health Insurance Portability and Accountability Act (HIPAA), I cannot report this to anyone without your permission." 3. "You really should tell your sexual partners, so they can be treated for syphilis." 4. "I realize you are embarrassed. Would you like to talk about the situation?"

1 This is an assessment question and should be asked to determine what the client has attempted has been unsuccessful.

The client tells the nurse in the bariatric clinic, "I have tried to lose weight on just about every diet out there but nothing works." Which statement is the nurse's best response? 1. "Which diets and modifications have you tried?" 2. "How much weight are you trying to lose?" 3. "This must be difficult. Would you like to talk?" 4. "You may need to get used to being overweight."

2 The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation in which the client's care is unsafe or inadequate.

The client tells the nurse, "I do not like my doctor and I want another doctor." Which statement is the nurse's best response? 1. "You should tell your doctor you are not happy with his care." 2. "Can you tell me what you don't like about your doctor's care?" 3. "I will notify my nursing supervisor and report your concern." 4. "I am sorry, but you really must keep this doctor until you are discharged."

3 A client should consult his or her HCP immediately if a mole or lesion shows any signs of melanoma—asymmetry, border irregularity, color change/variation, and diameter of 6 mm or more (ABCD).

The client tells the nurse, "I have a mole on my back which is darker and getting larger." Which intervention should the nurse implement first? 1. Tell the client to use corticosteroid cream on the area. 2. Recommend the client use SPF 15 when in the sun. 3. Instruct the client to notify his or her healthcare provider immediately. 4. Encourage the client to wear dark, woven clothing when outside.

2 This is the correct action to take; the nurse is an employee of the hospital directly involved in providing care and cannot witness documents for clients.

The client tells the primary nurse, "I just finished completing my living will and I need you to witness my signature." Which action should the nurse implement? 1. Witness the client's living will using an ink pen. 2. Explain that the nurse cannot witness this document. 3. Tell the client the document does not need a witness's signature. 4. Offer to have the hospital attorney to come notarize the form

3 Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.

The client who has had abdominal surgery is complaining of pain and tells the nurse, "I felt something pop in my stomach." Which intervention should the nurse implement first? 1. Check the client's apical pulse and blood pressure. 2. Determine the client's pain on a 1 to 10 pain scale. 3. Assess the client's surgical wound site. 4. Administer pain medication intravenously.

2 The Rapid Response Team was mandated by The Joint Commission. It is a team of healthcare professionals who respond to clients who are breathing but who the nurse thinks are in an emergency situation. A code is called if the client is not breathing.

The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client's surgical dressing.

4 The hemovac should be sunken in or depressed, indicating that suction is being applied, which indicates the hemovac is functioning appropriately.

The client who is 2 days postoperative abdominal surgery has a hemovac drainage tube. Which assessment data indicates the Jackson-Pratt (JP) is functioning appropriately? 1. The hemovac is round and has 40 mL of fluid. 2. The drainage tube is pinned to the dressing. 3. The hemovac insertion site is pink and has no drainage. 4. The hemovac has suction and is compressed.

4 Increasing the IV rate will provide the client with circulatory volume immediately. Therefore, this is the first intervention.

The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? 1. Notify the healthcare provider (HCP) immediately. 2. Assess the client's incisional wound. 3. Prepare to administer dopamine, a vasopressor. 4. Increase the client's intravenous (IV) rate.

1 The client that is morbidly obese will have a large abdomen that prevents the lungs from expanding, and predisposes the client to respiratory complications. Having the client use an incentive spirometer will help prevent respiratory complications.

The client who is morbidly obese is 8 hours postoperative gastric bypass surgery. Which nursing intervention is of the greatest priority? 1. Instruct the client to use the incentive spirometer. 2. Weigh the client daily in the same clothes and at the same time. 3. Apply sequential compression devices to the client's lower extremities. 4. Assist the client to sit in the bedside chair.

4 The physical therapist will assist in improving the circulation, strengthening muscles, and ambulating and transferring the client from a bed to a chair. This is the nurse's best response to explain why the client goes to physical therapy daily.

The client who was admitted to the rehabilitation unit because of a debilitative state asks the nurse, "Why do I have to go to physical therapy every day?" Which statement is the nurse's best response? 1. "The physical therapy will help you become more independent in caring for yourself." 2. "You must have at least 3 hours of therapy a day to be able to stay in this rehab unit." 3. "The multidisciplinary team determined that you should be in physical therapy daily." 4. "The physical therapist will help you with exercises to improve your muscle strength."

3 Autonomic dysreflexia is a life-threatening condition and can be considered a medical emergency requiring immediate attention. The nurse should not assess but should intervene, and the most common cause is a full bladder.

The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head.

3, 4, and 5 are correct. 3. Pushing the residual limb against a pillow will help toughen the end of the limb, which is needed when wearing a prosthetic limb. 4. The expected treatment for a client with impetigo is warm saline followed by soap and water for removal of crusts, followed by topical antibiotic cream. 5. Impetigo is very contagious, so wearing gloves and meticulous hygiene is essential when caring for this client

The client with a right below-the-knee amputation who also has impetigo is admitted to a rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Elevate the client's right leg on two pillows. 2. Refer the client to occupational therapy daily. 3. Encourage the client to push the residual limb against a pillow. 4. Use warm soap and water to remove the crusts secondary to impetigo. 5. Ensure all staff members wear gloves when caring for client.

2 The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted, it is probably a kink or a dependent loop, or the client is lying on the tubing. The nurse should first check for this prior to taking any other action.

The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the client's lung sounds. 2. Check for any kinks in the tubing. 3. Ask the client to take deep breaths. 4. Turn the client from side to side.

1 According to the NCLEX-RN® test blueprint under management of care, the nurse should be knowledgeable of referrals. The wound care nurse is trained to care for clients with colostomy and is knowledgeable in treating complications.

The client with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. Which intervention is most appropriate for the home health nurse (HH) to implement? 1. Refer the client to the wound care nurse. 2. Notify the client's healthcare provider. 3. Continue to monitor the stoma site. 4. Place Karaya paste over the excoriated area.

4 The electrical current in the body bounces off bone and goes through muscle. The heart is a muscle; therefore, the priority intervention is for the nurse to apply cardiac monitors to assess for lethal dysrythmias that may occur.

The client with an electrical burn is brought to the emergency department (ED). The entrance wound is on the right hand and the exit wound is on the left foot. Which intervention should the nurse implement first? 1. Place sterile gauze on the entrance and exit wounds. 2. Assess the client's vital signs. 3. Monitor the client's pulse oximetery. 4. Place the client on cardiac telemetry.

2 The rehabilitation commission of each state will help evaluate and determine whether the client can receive training or education for another occupation after injury.

The client with an upper extremity amputation tells the nurse, "I do everything with my right hand and now it is gone. I have no idea what I am going to do after I get discharged. How will I support my family? I will need to get a new job." Which statement is the nurse's best response? 1. "With time you will be able to use your left hand now." 2. "The state rehabilitation commission will help retrain you." 3. "You should ask the social worker about applying for disability." 4. "You are worried about how you will be able to support your family."

2 The ADA was passed in 1990 and ensures that a client with a disability has a right to be employed. Employers must make "reasonable accommodations," such as equipment or access ramps to facilitate employment of a person with a disability.

The client with bilateral amputations tells the nurse, "I was told I can't go back to my job because they do not have handicap accessible bathrooms or ramps." Which action by the nurse is most helpful to the client? 1. Discuss the situation with the multidisciplinary healthcare team. 2. Explain the Americans with Disabilities Act (ADA) to the client. 3. Contact the client's employer via telephone and discuss the situation. 4. Encourage the client to hire an attorney and sue the employer.

3 These ABGs indicate respiratory acidosis (ph <7.35, PaC O 2 >45) and hypoxemia (O2 <80); therefore, this client would warrant immediate intervention by the nurse. Untreated respiratory acidosis can result in death if not treated immediately.

The client with hypothyroidism and a diagnosis of myxedema coma is admitted to the critical care unit. Which assessment data warrants immediate intervention by the nurse? 1. The client's blood glucose level is 74 mg/dL. 2. The client's temperature is 96.2°F; AP, 54; R, 12; and BP, 90/58. 3. The client's ABG values are pH, 7.33; PaO2, 78; PaCO2, 48; HCO3, 25. 4. The client is lethargic and sleeps all the time.

3 The client's apical pulse (AP) and blood pressure (B/P) indicate the client is hemorrhaging; therefore, the nurse should first notify the client's surgeon.

The client with open surgery of the kidney has an AP 118 and B/P 88/58. Which intervention should the nurse implement first? 1. Obtain the client's pulse oximeter reading. 2. Check the client's last hemoglobin and hematocrit. 3. Notify the client's surgeon immediately. 4. Monitor the client's urine output.

1 These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe.

The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.

2 According to the NCSBN, case management is content included in the management of care. The case manager is responsible for collaborating with and coordinating the services provided by all members of the healthcare team, including the home healthcare nurse who will be responsible for directing the client's care after discharge from the rehabilitation unit. This is the nurse's best response.

The client's husband is frustrated and tells the nurse, "Everyone is telling me something different as to when my wife is going to be able to go home. I don't know whom to believe." Which statement is the rehabilitation nurse's best response? 1. "I can see you are frustrated. Would you like to talk about how you feel?" 2. "I will contact the case manager and have her talk to you as soon as possible." 3. "Do not worry. Your wife won't go home until you and she are both ready." 4. "Your wife's healthcare provider should be able to give you that information."

2 Bargaining: "I'll do anything for a few more years." The third stage involves the hope that the individual can somehow postpone or delay death. The client's comments indicate bargaining.

The client, who is terminally ill, tells the nurse, "I just want to live to see my grandson graduate in 2 months." Which stage of grief is the client experiencing? 1. Anger. 2. Bargaining. 3. Depression. 4. Acceptance.

Correct Answer: 3, 4, 1, 5, 2 3. The nurse needs to determine if the client is unresponsive prior to taking any action. If the client is unresponsive, then perform compressions. 4. The American Heart Association recommends 30 compressions followed by two breaths. 1. After completing compressions, open the client's airway to ensure a patent airway. 5. The nurse should then administer two breaths while the client's nose is pinched. 2. The nurse then must determine whether the client's heart is pumping by checking the carotid pulse.

The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Open the client's airway. 2. Check the client's carotid pulse. 3. Assess the client for unresponsiveness. 4. Perform compressions at a 30:2 rate. 5. Pinch the nose and give two breaths.

1 The nurse should realize the client probably has deep vein thrombosis, which is a medical emergency. The HCP should be notified immediately so the client can be started on IV heparin and admitted to the hospital.

The clinic nurse is assessing a client who is complaining of right leg calf pain. The right calf is edematous and warm to the touch. Which intervention should the nurse implement first? 1. Notify the clinic HCP immediately. 2. Ask the client how long the leg has been hurting. 3. Complete a neurovascular assessment on the leg. 4. Place the client's right leg on two pillows.

1 Children are being diagnosed with type 2 diabetes mellitus because of excessive intake of calories and lack of exercise. This is the priority problem. Many states are performing screening activities to identify children at risk for developing type 2 DM so that interventions can be made to delay or prevent the child being diagnosed with type 2 DM. Acanthosis nigricans (hyperinsulinemia) can be identified with simple, non-invasive screening.

The clinic nurse is caring for a 10-year-old client diagnosed with diabetes mellitus type 2. Which client problem is priority? 1. Altered nutrition, excessive intake. 2. Risk for low self-esteem. 3. Hypoglycemia. 4. Risk for loss of body part.

3 Daily baby aspirin is a medically accepted practice and prescribed by medical doctors. This is not an example of a CAM.

The clinic nurse is caring for clients using complementary alternative medicine (CAM). Which is not an example of CAM? 1. The client with hypothyroidism who takes Centella asiatica. 2. The type 2 diabetic client who takes cinnamon daily. 3. The client with coronary artery disease (CAD) who takes a daily baby aspirin. 4. The client who uses acupuncture to help quit smoking cigarettes.

3 A 24-week gestational woman with a BP of 142/96 would warrant intervention because the average systolic BP should be between 90 and 140 mm Hg and the diastolic BP should be between 60 and 85 mm Hg. This BP could indicate pregnancy-induced hypertension.

The clinic nurse is evaluating vital signs for clients being seen in the outpatient clinic. Which client would require nursing intervention? 1. The 10-month-old infant who has a pulse rate of 140 beats per minute. 2. The 3-year-old toddler who has a respiratory rate of 28 breaths per minute. 3. The 24-week gestational woman who has a BP of 142/96 mm Hg. 4. The 42-year-old client who has a temperature of 100.2°F (37.8oC).

1 This would be the most appropriate assignment because the nurse would not be exposed to any contagious diseases or dangerous radiological procedures.

The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to the staff nurse who is 4 months pregnant? 1. Have the staff nurse answer the telephone calls from clients. 2. Instruct the staff nurse to work in the radiology department. 3. Tell the staff nurse to work in the front desk triage area. 4. Assign the staff nurse to work in the oncology clinic.

3 For chemical injuries, the nurse should begin ocular irrigation with sterile, pH-balanced, physiological solution.

A client comes to the emergency department after having bleach splash in the eyes. Which intervention should the nurse implement first? 1. Cover both the eyes with sterile patches. 2. Assess the client's visual acuity. 3. Irrigate the eyes with sterile solution. 4. Elevate head of bed 45 degrees.

3 The nurse should have someone come talk to the client who is in a position to then investigate what happened on the night shift and determine why this happened. The day shift primary nurse does not have this authority.

A client on the vascular unit tells the day shift primary nurse that the night nurse did not answer the call light for almost 1 hour. Which statement would be most appropriate by the day shift primary nurse? 1. "The night shift often has trouble answering the lights promptly." 2. "I am sorry that happened and I will answer your lights promptly today." 3. "I will notify my charge nurse to come and talk to you about the situation." 4. "There might have been an emergency situation so your light was not answered."

1 The nurse should first assess the client's neurological status. It is not normal for an elderly person to have a change in behavior; this is cause for assessment.

A wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where he is, and is not acting like his usual self. Which intervention should the nurse implement first? 1. Perform a neurological assessment. 2. Notify the client's healthcare provider. 3. Ask the wife to explain more about the behavior. 4. Determine when the client last had something to eat.

2 The first action is to increase the client's oxygen to 100%.

In the intensive care unit (ICU), the critical care nurse assesses a client diagnosed with an asthma attack who has a respiration rate of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement first? 1. Call a Rapid Response Team (RRT). 2. Increase the oxygen to 10 LPM. 3. Check the client's ABG results. 4. Administer the fast-acting inhaler

2 The yearly flu shot is the best way to help prevent getting sick during the winter months, since the flu can cause serious illness, and even death, in the elderly. Alport syndrome is also known as chronic hereditary nephritis.

The 78-year-old client with Alport syndrome asks the clinic nurse, "What should I do so I won't get sick this winter?" Which priority statement is the nurse's best response? 1. "You should not be around any crowds during the winter months." 2. "It is recommended you get a flu vaccine yearly." 3. "You need to eat three well-balanced meals a day." 4. "Dress warmly when it is less than 40 degrees Fahrenheit outside."

3 A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behavior.

The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first? 1. Tell the UAP to change it immediately. 2. Ask the UAP why the sharps container has not been changed. 3. Change the sharps container as per clinic policy. 4. Document the situation and place a copy of the documentation in the employee file.

3 The nurse's priority intervention should be to address the grieving process of the family.

The client in a multiple car crash dies in the emergency department. Which priority intervention should the emergency department nurse implement when addressing the needs of the client's family? 1. Ask if the client wanted to be a tissue donor. 2. Give the family the client's personal belongings. 3. Escort the family to a private room to grieve. 4. Determine which funeral home should be contacted.

1 An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease. If the client can move the toes and denies tingling or numbness, then no further action should be taken.

The client is 1 week postoperative for right below-the-knee amputation secondary to arterial occlusive disease. The nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first? 1. Assess for paresthesia and paralysis. 2. Utilize the Doppler device to auscultate the pulse. 3. Place the client's leg in the dependent position. 4. Wrap the client's left leg in a warm blanket.

2 Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth. This response gives the client factual information.

The client with hepatitis asks the nurse, "Is there any herb I can take to help my liver get better?" Which statement is the nurse's best response? 1. "You should ask your healthcare provider about taking herbs." 2. "Milk thistle is a powerful oxidant and promotes liver cell growth." 3. "You should not take any medication that is not prescribed." 4. "Why would you want to take any herbs?"

4 This is the most important question because if the client is pregnant, the x-rays can harm the fetus.

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is most important for the nurse to ask the client? 1. "Have you ever had a chest x-ray before?" 2. "Can you hold your breath for a minute?" 3. "Do you smoke or have you ever smoked cigarettes?" 4. "Is there any chance you may be pregnant?"

1 This position allows for access to the client's back area. The chest tube for a hemothorax is positioned low and posterior to allow for gravity to assist in the removal of fluid from the thoracic area.

The emergency department nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure? 1. Have the client sit upright and bend over the over bed table. 2. Place the client in the left lateral recumbent position. 3. Have the client sit on the side of the bed with the back arched like a Halloween cat. 4. Place the client lying on the back with the head of the bed up 45 degrees.

2 The employee must submit to a urine drug screen anytime there is an injury. This is standard practice by many employers to help determine whether the employee was under the influence during the time of the accident. Workers' compensation will not be responsible if the employee is under the influence of alcohol or drugs.

The employee health nurse is caring for a male employee who reports tripping and is complaining of right knee pain. There is no visible injury, and the client has a normal neurovascular assessment. Which intervention should the nurse implement? 1. Request the employee to return to work. 2. Obtain a urine specimen for a drug screen. 3. Send the client to the emergency department. 4. Place a sequential compression device on the leg.

1 The nurse should first determine whether there is a fire or whether someone accidentally or purposefully pulled the fire alarm. Because this is a clinic, not a hospital, the nurse should keep calm and determine the situation before taking action.

The fire alarm starts going off in the family practice clinic. Which action should the nurse take first? 1. Determine whether there is a fire in the clinic. 2. Evacuate all the people from the clinic. 3. Immediately call 911 and report the fire. 4. Instruct clients to stay in their rooms and close the doors.

3 Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic.

The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be admin- istered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client's output is greater than the intake.

2 The occupational therapist could assist the client in identifying ways to save energy when performing activities of daily living. Myasthenia gravis is a neurological condition that causes skeletal muscle weakness.

The home health (HH) nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement? 1. Talk to the client's husband about helping around the house more. 2. Contact the HH occupational therapist to discuss the client's concern. 3. Allow the client to verbalize her feelings of being exhausted. 4. Recommend the client make an appointment with her HCP.

2 Bilateral breath sounds indicate the left lung has re-expanded and the treatment is effective.

The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site.

2 The nurse should first look at his or her watch and time the seizure. Assessment is the first intervention because there is no action the nurse can implement to stop or intervene with the seizure.

The nurse enters the room, and the client is beginning to have a tonic-clonic seizure. Which action should the nurse implement first? 1. Identify the first area that began seizing. 2. Note the time the client's seizure began. 3. Pad the siding of the client's bed rails. 4. Provide the client with privacy during the seizure.

1 The client's ability to maneuver a wheelchair indicates that the client has progressed in therapy.

The nurse in a rehabilitation facility is evaluating the progress of a female client who sustained a C-6-C-7 spinal cord injury. Which outcome indicates the client is improving? 1. The client can maneuver the automatic wheelchair into the hallway. 2. The client states she will be able to return to work in a few weeks. 3. The client uses eye blinks to communicate yes and no responses. 4. The client's husband built a wheelchair ramp onto their house.

3 The devout Mormon client wears a religious undershirt that should not be removed; this action indicates cultural sensitivity on the part of the nurse

The nurse is admitting a client with an abdominal aortic aneurysm who is a member of the Church of Jesus Christ of Latter-Day Saints (Mormon). Which action by the nurse indicates cultural sensitivity to the client? 1. The nurse does not insist on administering a blood transfusion. 2. The nurse pins the client's amulet to the client's pillow 3. The nurse keeps the client's undershirt on during the bath. 4. The nurse notifies the client's curandero of the admission.

3 Impaired gas exchange is the priority problem for this client. If the client does not have adequate gas exchange, the client will die. Remember Maslow's Hierarchy of Needs.

The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client's priority nursing diagnosis? 1. Activity intolerance. 2. Altered coping. 3. Impaired gas exchange. 4. Self-care deficit.

1, 3, and 4 are correct. 1. This is a goal for EOL care. 3. This is a goal for EOL care. 4. This is a goal for EOL care.

The nurse is discussing end-of-life care (EOL) with the client diagnosed with pancreatic cancer. Which statements are the goals for end-of-life care? Select all that apply. 1. To provide comfort and supportive care during the dying process. 2. To plan and arrange the funeral for the client. 3. To improve the client's quality of life for the remaining time. 4. To help ensure a dignified death for the client and family. 5. To assist with the financial cost of the dying process.

3 Evidence-based practice is the conscientious use of current best evidence in making decisions about nursing care. Using the "evidence," or research, to teach a client is evidence-based practice.

The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice (EBP)? 1. Turn on the tap water to help a client urinate. 2. Use two identifiers to identify a client before a procedure. 3. Educate a client based on current published information. 4. Read nursing journals about the latest procedures.

2 The nurse should assess the client with a thyroidectomy for hemorrhaging every 2 hours. Neck edema, irregular breathing, and frequent swelling are signs of hemorrhaging; therefore, the nurse should assess this client first.

The nurse is working on an endocrinology unit. Which client should the nurse assess first? 1. The client diagnosed with diabetes insipidus who has polyuria and polydipsia. 2. The client who is 1 day postoperative thyroidectomy who has neck edema. 3. The client who has hypoparathyroidism who has painful muscle cramps and irritability. 4. The client diagnosed with Addison's who has weakness, fatigue, and anorexia

4 Part of the delegation process is to evaluate the UAP's performance andthe nurse should praise any action on the part of the UAP that ensures the client's safety.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Explain that the client on a ventilator should not be bathed. 4. Give the UAP praise for performing the bath safely.

3 Since the UAP gave the nurse this information, the nurse must assess the client prior to taking any further action.

The unlicensed assistive personnel (UAP) tells the nurse the client who had a thyroidectomy has a T 104°F, P 128, RR 26, B/P 164/88. Which intervention should the nurse implement first? 1. Prepare to administer the beta-adrenergic blocker propranolol (Inderal). 2. Notify the healthcare provider immediately. 3. Assess the client's vital signs and surgical dressing. 4. Administer acetaminophen (Tylenol) PO STAT.

1 Because the UAP is informing the nurse of pertinent information, the nurse should assess the client to determine which action to take.

The unlicensed assistive personnel (UAP) tells the nurse the client with a right above-the-knee amputation has a large amount of bright red blood on the right leg residual limb. Which action should the nurse implement? 1. Assess the client's residual limb dressing. 2. Tell the UAP to take the client's pulse and blood pressure. 3. Remove the dressing to assess the incision. 4. Request the UAP to reinforce the dressing.

3 The nurse must first assess the client since the UAP gave the nurse the information.

The unlicensed assistive personnel (UAP) tells the nurse the client with thyroid cancer who is terminally ill is having deep-rapid breathing, but then doesn't breathe for about a minute. Which intervention should the nurse implement first? 1. Explain the client is having Cheyne-Stokes respirations. 2. Notify the hospital chaplain to come to the client's room. 3. Go to the client's room immediately and assess the client. 4. Contact the client's family that the client's death is near.

3 The primary nurse cannot ask another nurse to administer medication that he or she prepared. The nurse preparing the injection must administer the medication. This action requires the charge nurse to intervene.

Which action by the female primary nurse would warrant immediate intervention by the charge nurse on the rehabilitation unit? 1. The primary nurse tells the unlicensed assistive personnel (UAP) to escort a client to the swimming pool. 2. The primary nurse evaluates the client's plan of care with the family member. 3. The primary nurse asks another nurse to administer an injection she prepared. 4. The primary nurse requests another nurse to watch her clients for 30 minutes

2 The client has been given devastating news. When all the information in the options is expected and not life threaten- ing, then psychological issues have priority. This client should be seen first.

Which client should the cardiac nurse assess first after receiving the p.m. shift report? 1. The client who is completing the second unit of PRBCs. 2. The client who is crying after being informed of a terminal diagnosis. 3. The client who refused to eat the dietary tray but got food from home. 4. The client who became short of breath ambulating in the hallway.

1 This client with dyspnea and a respiration rate of 12 has signs/symptoms of a respiratory complication and should be assessed first because ascending paralysis at the C-6 level could cause the client to stop breathing.

Which client should the charge nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%.

3 The orange-colored urine is secondary to rifampin, an antitubercular medication, and a non-productive cough is expected. Therefore, this client is stable and should be assigned to a new graduate nurse.

Which client should the charge nurse assign to the new graduate on the respiratory unit? 1. The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10. 2. The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. 3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 91% and has a CRT >3 seconds.

4 Steroids are excreted as glucocorticoids from the adrenal gland and are responsible for insulin resistance by the cells, which may cause hyperglycemia; there- fore, the nurse should monitor the glucose level.

Which laboratory data should the nurse monitor for the client receiving the intra- venous Solu-Medrol? 1. Potassium level. 2. Sodium level. 3. Liver enzymes. 4. Glucose level.

Correct Answer: 3, 1, 5, 2, 4 3. This patient has a change in normal sputum production. Frequently, patients diagnosed with obstructive pulmonary diseases are placed on steroid therapy. Steroid therapy can mask an infection. The only symptom of an infection may be a change in the color of the sputum. 1. This patient has a deep wound that needs to be assessed. 5. This test can be performed by the nurse with a portable machine. The HCP may need to adjust the patient's medication based on the results. 2. This is a medication to increase the patient's WBC production. 4. This is expected behavior for a client with Alzheimer's disease.

The home health (HH) nurse is planning to make rounds for the day. List the order the clients should be seen by priority. 1. The 29-year-old client diagnosed with spinal cord injury (SCI) post-motor vehicle accident (MVA) who needs a dressing changed on a Stage IV pressure area. 2. The 56-year-old client diagnosed with breast cancer who needs an injection of filgrastim (Neupogen) subcutaneously. 3. The 67-year-old client diagnosed with emphysema who called to report that the sputum is a rusty color this morning. 4. The 80-year-old client diagnosed with Alzheimer's disease who is confused and wandering around the house. 5. The 72-year-old client diagnosed with atrial fibrillation who needs a prothrombin time performed and called to the HCP.

3 The nurse should review the client's referral form and other pertinent data concerning the client's condition first before taking any further steps. The nurse may need to contact the referring agency if the information is unclear or if important information is missing. This is assessment.

The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first? 1. Prepare all the needed equipment for the visit. 2. Call the client to arrange a time for the visit. 3. Review the client's referral form/pertinent data. 4. Make the necessary referrals for the client.

4 The client is reporting an infection at insertion sites into the bone, which can lead to osteomyelitis. This client is exhibiting a potentially life-threatening condition and should be seen first.

The home health (HH) nurse is scheduling visits for the day. Which client should the nurse visit first? 1. The client with an L-4 SCI who is complaining of a severe, pounding headache. 2. The client with amyotrophic lateral sclerosis (ALS) who is depressed and wants to die. 3. The client with Parkinson's disease who is walking with a short, shuffling gait. 4. The client with a C-5 SCI who reports redness and drainage at the Halo vest sites.

2 Nurses in home health have been given the authority to pronounce death for clients who are on service and death is imminent. This intervention should be implemented first.

The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client's family is at the bedside. Which intervention should the HH nurse implement first? 1. Contact the agency's chaplain. 2. Pronounce the client's death. 3. Ask the family to leave the bedside. 4. Call the client's funeral home.

4 The client with chronic atrial fibrillation is at risk for pulmonary emboli, a potentially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first.

The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first? 1. The client diagnosed with hypertension who is reporting a BP of 148/92. 2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%. 3. The client diagnosed with congestive heart failure who has edematous feet. 4. The client diagnosed with chronic atrial fibrillation who is having chest pain.

2 Because the client has difficulty breathing while lying in bed, allowing the client to sit in a recliner will help the client; therefore, this is the priority intervention.

The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client's oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths.

1 The client with end-stage COPD usually prefers a cool climate, with fans to help ease breathing. A warm area would increase the effort the client would require to breathe. This action would warrant intervention by the nurse.

The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client's oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner.

3 This response allows the client to make his or her own decision. It validates that the nurse heard the concern but does not advise the client.

The hospice client asks the nurse, "What should I do about my house? My son and daughter are fighting over it." Which statement is the nurse's best response? 1. "I think you should tell your children that you will leave the house to a charity." 2. "I would sell the house and go on an extended vacation and spend the money." 3. "What do you want to happen to your house? It is your decision." 4. "Wait and let your children fight over the house after you are gone."

1 A terminally ill client should be allowed comfort measures even when the activity would normally not be encouraged or allowed. The client can receive sliding-scale insulin, if needed, to cover the ice cream.

The hospice nurse caring for a client diagnosed with diabetes mellitus type 2 observes the client eating a bowl of ice cream. Which intervention should the nurse implement first? 1. Allow the client to enjoy the ice cream. 2. Check the client's blood glucose. 3. Remind the client not to eat ice cream. 4. Suggest the client eat low-fat sweets.

3 This is an important statement for the UAP to understand. If information revealed to the UAP is necessary to provide appropriate care to the client, then the information must be shared on a need- to-know basis with the healthcare team.

The hospice nurse is discussing the clients' care with the unlicensed assistive personnel (UAP). Which statement contains the best information about caring for a client with end-stage heart failure who is dying? 1. "Perform as much care for the client as possible to conserve his or her strength." 2. "Do not get too attached to the client because it will hurt when he or she dies." 3. "Be careful not to promise to withhold healthcare information from the team." 4. "The client may want to talk about his or her life, but you should discourage that."

1 Encouraging the client to review his or her life experiences assists the client to come to a closure of his or her life. This is an important intervention the volunteer can perform.

The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer? 1. Sit with the client while he or she reminisces about life experiences. 2. Give the client a sponge bath and rub lotion on the bony prominences. 3. Provide spiritual support for the client and family members. 4. Check the home to see that all necessary medical equipment is available.

1 A social worker is qualified to assist the client with referrals to any agency or personnel that may be needed after the client is discharged home.

The husband of a client diagnosed with a terminal lung cancer asks the nurse, "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate? 1. Notify the social worker about the husband's concerns. 2. Contact the hospital chaplain to talk to the husband. 3. Leave a note on the chart for the HCP to talk to the husband. 4. Reassure the husband that everything will be all right.

2 This is not an appropriate intervention because the client is at risk for increased intracranial pressure (ICP); therefore, the client should not be placed on the stomach. The prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures, and done in rehabilitation.

The intensive care unit nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis secondary to a cerebrovascular accident. Which action by the UAP requires the nurse to intervene? 1. The UAP performs passive range-of-motion (ROM) exercises for the client. 2. The UAP places the client on the abdomen with the head to the side. 3. The UAP uses a lift sheet when moving the client up in bed. 4. The UAP praises the client for attempting to feed him- or herself.

1 Mexican American families are close-knit communities and often prefer to care for their own family members; therefore, they would not seek hospice or palliative care. The nurse should attempt to help the client understand the philosophy, the benefits, and the help hospice can give the client and family.

The male Mexican American client, who is terminally ill, refuses hospice services because he says it is "giving up" and he is not going to die. Which is the most appropriate action by the nurse? 1. Discuss the philosophy and services of palliative care with the client. 2. Take no other action and support the client's decision. 3. Contact the client's healthcare provider to discuss the prognosis. 4. Talk to the client's family members about his choice to refuse hospice

2 Assessment is the first part of the nursing process and is always priority. The intensity of the renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.

The male client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Request the client to urinate in a urinal. 2. Assess the client's pain. 3. Increase the client's oral fluid intake. 4. Strain the client's urine.

3 Direct pressure is applied to the site and then the client is placed on the right side to maintain site pressure for at least 2 hours. Turning the client to the left side warrants intervention by the nurse so the client will not hemorrhage.

The male client is 30 minutes post-procedure liver biopsy. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene? 1. The UAP offered the client a urinal to void. 2. The UAP gave the client a glass of water. 3. The UAP turned the client on the left side. 4. The UAP took the client's vital signs.

4 The case manager is responsible for coordinating the total rehabilitative plan, collaborating with and coordinating the services provided by all members of the healthcare team, including the home healthcare nurse who will be responsible for directing the client's care after discharge from the rehabilitation unit.

The male client is placed in a double hip spica cast for 3 months. The client's wife tells the nurse, "My husband said we are supposed to talk to his case manager. What is a case manager?" Which statement is the nurse's best response? 1. "A case manager discusses the cost and insurance issues concerning the rehabilitation." 2. "The case manager is responsible for the medical treatment regimen for your husband." 3. "The case manager is a member of the team who will assist your husband in finding another job." 4. "The case manager is a nurse who will coordinate the rehabilitation team and keep you informed."

3 After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this elevated blood pressure warrants notifying the healthcare provider. Erythropoietin therapy is contraindicated in clients with hypertension that cannot be controlled.

The male client with chronic kidney disease has received the initial dose of erythropoietin, a biological response modifier, 1 week ago. Which data warrants the nurse to notify the healthcare provider? 1. The client's pulse oximeter reading of 95%. 2. The client has a platelet count of 155,000. 3. The client has a blood pressure reading of 184/102. 4. The client has a tympanic temperature of 99.8°F.

4 This action shows the nurse being the client's advocate. Offering to go talk to the HCP about the amputation and making sure the HCP hears the client's opinion is being a client advocate. Another discussion may change the client's decision, but either way, client advocacy is supporting the client's decision.

The male client with peripheral vascular disease tells the nurse, "I know my foot is really bad. My doctor told me I don't have any choice and I must have an amputation, but I don't want one." Which action supports the nurse being a client advocate? 1. Support the medical treatment, and recommend the client have the amputation. 2. Recommend the client talk to his wife and children about his decision. 3. Explain to the client that he has a right to a second opinion if he doesn't want an amputation. 4. Tell the client she will go with him to discuss his decision with the doctor.

Correct Answer: 1, 4, 3, 2, 5 1. The bleeding must be stopped. The nurse should don unsterile gloves and apply pressure to the bleeding site for a minimum of 5 minutes. 4. When the bleeding has stopped, the client can be assisted back to bed so a thorough assessment of the injuries can be performed. 3. The site should be redressed when possible to protect the wound from infectious organisms. 2. Once the nurse has been able to assess the client and has the client in a safe environment, then the nurse should notify the surgeon. 5. The occurrence should be noted on a report form and the appropriate hospital personnel notified, but this can be done after caring for the client.

The male post-op femoral popliteal client notifies the desk via the intercom system he has fallen and is now bleeding. Which interventions should the nurse implement? Rank in order of performance. 1. Apply pressure directly to the bleeding site. 2. Notify the surgeon of the fall and the bleeding. 3. Redress the site with a sterile dressing. 4. Assist the client to a recumbent position in the bed. 5. Make out an occurrence report and document the fall.

1 The daughter lives in a "nearby" city. The client should not be moved any- where until the daughter arrives.

The matriarch of a family has died on the vascular unit. The family tells the nurse the daughter is coming to the hospital from a nearby city to see the body. Which intervention should the nurse implement? 1. Plan to allow the daughter to see the client in the room. 2. Take the client to the morgue for the daughter to view. 3. Request the family call the daughter and tell her not to come. 4. Explain to the daughter that the unit is too busy for family visitation.

3 Wound dehiscence is the premature "bursting" open of a wound along surgical suture, and is an emergency that would require the nurse to assess this client first.

The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first? 1. The client who has a paralytic ileus and has absent bowel sounds. 2. The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen. 3. The client who is 6 hours postoperative and has an abdominal wound dehiscence. 4. The client who had a liver transplant and is being transferred to the rehabilitation unit.

4 The wound care nurse's primary role is to address non-healing pressure ulcers. This referral is the priority intervention.

The multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a Stage 2 pressure ulcer over the sacral area that is not healing. Which priority intervention should the client's home health (HH) nurse recommend? 1. Recommend the client get a hospital bed with a trapeze bar. 2. Recommend a home health aide provide care 7 days a week for the client. 3. Recommend the client be transferred to a skilled nursing unit. 4. Recommend a referral to the home healthcare agency wound care nurse.

4 A 22-year-old client who experienced a traumatic brain death may be a good candidate for organ donation. Most tissue and organ banks prefer to be the ones to approach the family. This is the best referral.

The neurologist has explained to the family of a 22-year-old client with a traumatic brain injury placed on a ventilator after a motor vehicle accident that the client does not have any brain function. Which referral is appropriate at this time? 1. A local funeral director. 2. A hospice agency. 3. A home health nurse. 4. A tissue and organ bank.

1 The Joint Commission is an organization that monitors healthcare facilities for compliance with standards of care. Accreditation is voluntary, but most third-party payers will not reimburse a facility that is not accredited by some outside organization.

The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization? 1. The Commission reviews facilities for compliance with standards of care. 2. Accreditation by the Commission guarantees the facility will be reimbursed for care provided. 3. Accreditation by the Commission reduces liability in a legal action against the facility. 4. The Commission eliminates the need for Medicare to survey a hospital.

2 The preceptor should recommend that the new graduate use some tool to organize the work so important tasks, such as medication administration and taking vital signs, are not missed.

The new graduate nurse on the endocrine unit is having difficulty completing the workload in a timely manner. Which suggestion could the preceptor make to help the new graduate become more organized? 1. Suggest the new nurse take a break whenever the nurse feels overwhelmed with tasks. 2. Tell the new nurse to start the shift with a work organization sheet for the assigned clients. 3. Instruct the new nurse to take five deep breaths at the beginning of the shift, and then begin. 4. Review each day's assignments for the new nurse and organize the work for the new nurse.

2 The first step is an informal meeting with the staff member to discuss the inappropriate attitude and how it affects the staff. The manager should document the conversation informally with the date and time (the staff member does not need to see this documentation) for future reference. If the situation is not resolved, a formal counseling must take place.

The newly hired nurse manager has identified that whenever a specific staff member is unhappy with an assignment, the entire unit has a bad day. Which action should the unit manager take to correct this problem? 1. Determine why the staff member is unhappy. 2. Discuss the staff member's attitude and the way it affects the unit. 3. Place the staff member on a counseling record for the behavior. 4. Suspend the staff member until the behavior improves.

2 The ethical principle of veracity is the duty to tell the truth.

The night nurse enters the client's room and finds the client crying. The client asks the nurse, "Am I dying? I think something is terribly wrong with me, but no one is telling me." The nurse knows the client has pancreatic cancer and has less than 6 months to live. Which response is an example of the ethical principle of veracity? 1. "You are concerned no one is telling you something is wrong." 2. "Your diagnosis is pancreatic cancer." 3. "If you feel something is wrong you should speak with your doctor in the morning." 4. "What makes you think there is something wrong and you are dying?"

2 The step the nurse did not take was to verify the client's armband against the MAR. Checking the identification band against the MAR would have prevented the error.

The nurse administering medications to clients on a medical unit discovers the wrong medication was administered to a client, Mrs. Jones. Mrs. Jones had replied she was Mrs. Smith when the nurse asked her name from the MAR. Which step in medication administration did the nurse violate when administering the medication? 1. Asking the client to repeat her name. 2. Verifying the client's armband with the MAR. 3. Checking the medication against the MAR. 4. Documenting the medication on the MAR.

2 The LPN could administer routine parenteral medications. This is the best task to assign to the LPN.

The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow.

1 The LPN can administer medications to clients; therefore, this task is appropriate for the nurse to assign to the LPN.

The nurse and LPN have been assigned to care for clients on a neurology unit. Which nursing task is most appropriate to assign to the LPN? 1. Administer the adrenocorticotropic hormone to the client with multiple sclerosis. 2. Take the vital signs for the client who is experiencing status epilepticus. 3. Assist the client with Parkinson's disease to ambulate to the bathroom. 4. Assess the client newly admitted who has pneumonia and restless legs syndrome.

1 An abductor pillow is used for a client with a THR to help prevent hip dislocation and the UAP can place the pillow between the client's legs. This task is appropriate to delegate.

The nurse and the unlicensed assistive personnel (UAP) are caring for a 74-year-old client who is 3 days postoperative right total hip replacement (THR). Which nursing task should be delegated to the UAP? 1. Place the abductor pillow between the client's legs. 2. Ensure the client stays on complete bed rest. 3. Feed the client the evening meal. 4. Check the client's right hip surgical dressing.

3 The UAP can apply non-medicated ointment to protect the client's perineum when bathing and changing the client's incontinence pads. This will protect the client from skin breakdown.

The nurse and the unlicensed assistive personnel (UAP) are caring for a client on a medical unit who has difficulty swallowing and is incontinent of urine and feces. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the client's PEG feeding tube for patency. 2. Place DuoDERM wound care patches on the client's coccyx. 3. Apply non-medicated ointment to the client's perineum. 4. Suction the client during feeding to prevent aspiration.

4 The nurse should not delegate to the UAP feeding a client who is not stable and at risk for complications during feeding, as a result of dysphagia. This requires judgment that the UAP is not expected to possess.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. 2. Request the UAP change the linens for the 89-year-old client with fecal incontinence. 3. Tell the UAP to assist the 54-year-old client with a bowel management program. 4. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis.

3 The UAP can assist the client to the bathroom as part of the bowel training; the nurse is responsible for the training, but the nurse can delegate this task.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a rehabilitation unit. Which nursing task is most appropriate for the nurse to delegate to the UAP? 1. Flush the triple-lumen lines on a central venous catheter. 2. Demonstrate for the client how to ambulate with a walker. 3. Assist with bowel training by escorting the client to the bathroom. 4. Apply corticosteroid cream to the client with allergic dermatitis.

3 The leg should be elevated to prevent postoperative edema; therefore, this task could be delegated to the UAP.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a vascular unit. Which task should the nurse delegate to the UAP? 1. Apply bilateral sequential compression devices to the client with deep vein thrombosis. 2. Accompany the client with thromboangiitis obliterans outside to smoke a cigarette. 3. Elevate the leg of the client who is one day postoperative femoral-popliteal bypass. 4. Perform Doppler studies on the client with right upper extremity lymphedema.

1 The unlicensed assistive personnel (UAP) can clean the perineal area of a client who is on bed rest and who has an indwelling catheter. Because the client is stable, this nursing task could be delegated to the UAP.

The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate? 1. Provide indwelling catheter care to a client on bed rest. 2. Evaluate the client's 8-hour intake and output. 3. Give a bath to the client who is third-spacing. 4. Administer a cation-exchange resin enema to a client.

3 This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently.

3 The nurse cannot delegate teaching to the UAP.

The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform? 1. Measure the client's output from the indwelling catheter. 2. Record the client's intake and output on the I&O sheet. 3. Instruct the client on appropriate fluid restrictions. 4. Provide water for a client diagnosed with acute polynephritis.

1 The nurse and the UAP should protect themselves from injury. A lifting device should be used before attempting to move the client.

The nurse and unlicensed assistive personnel (UAP) are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. Which action is priority when moving the client in the bed? 1. Obtain a lifting device made for lifting heavy clients. 2. Do not attempt to move the client because of the weight. 3. Get another UAP to help move the client in the bed. 4. Tell the family that the client must assist in moving in the bed.

2 The client who received a narcotic analgesic 30 minutes ago is at risk for falling because of the effects of the medication; therefore, the UAP should not ambulate this client. The nurse should intervene.

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? 1. The UAP empties the indwelling catheter bag for the client with transurethral resection of the prostate (TURP). 2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall. 3. The UAP provides apple juice to the client with a nephrectomy who has just been advanced to a clear liquid diet. 4. The UAP applies moisture barrier cream to the elderly client with urinary incontinence who has an excoriated perianal area.

4 The client just returning from surgery and the PACU should be assessed immediately by the nurse. The UAP is not qualified to identify an unstable situation.

The nurse and unlicensed assistive personnel (UAP) are caring for clients on an endocrinology unit. Which task should not be delegated to the UAP? 1. Ambulate the client who had a unilateral adrenalectomy. 2. Change the linens on the client with acute thyrotoxicosis who is diaphoretic. 3. Bring ice-cold water to the client diagnosed with diabetes insipidus. 4. Take the vital signs of a client who has just returned from the post-anesthesia care unit (PACU).

4 The UAP is trained to take vital signs on a client who is stable. This task could safely be delegated by the nurse.

The nurse and unlicensed assistive personnel (UAP) are working in a family practice clinic. Which task should the nurse delegate to the UAP? 1. Give the client sample medications for a urinary tract infection (UTI). 2. Show the client how to use a self-monitoring blood glucometer. 3. Answer the telephone triage line and take messages from clients. 4. Take the vital signs of a client scheduled for a physical examination.

2 This is the priority action because the nurse will ensure the UAP knows how to apply SCDs correctly, thereby enabling the nurse to delegate the task to the UAP successfully in the future.

The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take? 1. Tell another UAP to put the SCDs on the client. 2. Demonstrate the procedure for applying the SCDs. 3. Perform the task and apply the SCDs to the client. 4. Request the UAP watch the video demonstrating this task.

1 The nurse should provide instruction and support to the UAP. This is the best response.

The nurse delegates post-mortem care to the unlicensed assistive personnel (UAP). The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP? 1. "It can be uncomfortable. I will go with you and show you what to do." 2. "The client is already dead. You cannot hurt him now." 3. "There is nothing to it; it is just a bed bath and change of clothes." 4. "Don't worry. You can skip it this time but you need to learn what to do."

1 Effective group process involves all members of the group.

The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of effective group process? 1. The nurse involves all committee members in the discussion. 2. The nurse makes sure all members of the group agree with the decisions. 3. The nurse asks two of the committee members to do the work. 4. The nurse does not allow deviation from the agenda to occur

4 The client with varicose veins would be expected to have deep aching pain in the legs; therefore, the nurse who is being floated to the vascular unit could be assigned to this client.

The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse? 1. The client with the femoral-popliteal bypass who has paraesthesia of the foot. 2. The client with an abdominal aortic aneurysm who is complaining of low back pain. 3. The client newly diagnosed with chronic venous insufficiency who needs teaching. 4. The client with varicose veins who is complaining of deep, aching pain of the legs.

2 The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; there- fore, this client should be assessed first.

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with arterial occlusive disease who has intermittent claudication. 2. The client on strict bed rest who is complaining of calf pain and has a reddened calf. 3. The client who complains of low back pain when lying supine in the bed. 4. The client who is upset because the food doesn't taste good and is cold all the time.

4 The nurse should assess this client first because if the client does not stay in the bed, the clot in the calf muscle may dislodge and result in a pulmonary embolus. The client with a DVT must be on bed rest.

The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is refusing to eat the high protein meal. 2. The client with varicose veins who is refusing to wear thromboembolic hose. 3. The client with arterial occlusive disease who is refusing to elevate their legs. 4. The client with deep vein thrombosis who is refusing to stay in the bed.

2 The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation; therefore, the nurse should assess this client first.

The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson's disease who is experiencing "pill rolling." 4. The client with Huntington's disease who has writhing, twisting movements of the face.

1 Pain should be assessed, even if it is expected for the client's diagnosis, if the other clients are stable.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The client with peptic ulcer disease who is complaining of acute epigastric pain. 2. The client with acute gastroenteritis who is upset and wants to go home. 3. The client with inflammatory bowel disease who is receiving total parental nutrition. 4. The client with hepatitis B who is complaining and who is jaundiced and anorexic.

3 A hard, rigid abdomen indicates peritonitis, which is a life-threatening emergency. This client should be assessed first.

The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? 1. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants. 2. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset. 3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen. 4. The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10.

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

The nurse has received the shift report. Which client should the nurse assess first? 1. The client with a deep vein thrombosis who is complaining of dyspnea and coughing. 2. The client diagnosed with Buerger's disease who has intermittent claudication. 3. The client diagnosed with an aortic aneurysm who has an audible bruit. 4. The client with acute arterial ischemia who has bilateral palpable pedal pulses.

2 Prostigmin promotes muscle function in clients diagnosed with myasthenia gravis. This medication should always be administered on time to prevent loss of muscle tone, especially the muscles of the upper respiratory tract. This is the priority medication to administer at this time.

The nurse in a long-term care facility is administering medications to a group of clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid (aspirin) to a client diagnosed with cerebrovascular disease. 2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis. 3. Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection. 4. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy.

Correct Answer: 1, 3, 4, 2, 5 1. This client may have overdosed accidently or on purpose. This is a physiological problem and the nurse must determine which intervention is required next. This is a potentially life-threatening situation, so the nurse should return this phone call first. 3. The client with hypothyroidism is report- ing signs of hyperthyroidism, indicating the client is overdosing on the thyroid hormone replacement and needs to be seen in the clinic. This is a physiological problem; therefore, the nurse should call this client second. 4. The pharmacist needs to know if the substitution can be made in order to fill this prescription. This call should be returned third. 2. The nurse needs to discuss the prescribed medication with the HCP to see if a different, less expensive medication would work as well for the client, or if there is an alternative medication program that could be discussed with the client. This phone call should be returned fourth. 5. The nurse must first determine where the breakdown in the communication of the results of the MRI occurred, then obtain the results and provide them to the HCP prior to returning the call. This phone call can be returned last.

The nurse in an outpatient clinic is returning telephone calls. Rank the calls in the order they should be returned, with the highest priority call first. 1. The call from a husband who states his wife started on an antidepressant and now will not wake up. 2. The call from a client who states the medication that was prescribed for her diabetes mellitus type 2 is too expensive. 3. The client with hypothyroidism who is reporting feeling hot, having hand tremors, and having diarrhea. 4. The call from the pharmacist wanting an authorization to change a medication from a trade name to a generic name drug. 5. The call from the client who had a magnetic resonance imaging (MRI) scan 2 days ago and has not received the results.

4 The client on peritoneal dialysis who has a hard, rigid abdomen has a potentially life-threatening complication; this client should be assessed first and then sent to the hospital.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has a hemoglobin of 9.0 mg/dL and hematocrit of 26%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is reporting a 3.6 kg weight gain and is refusing dialysis. 4. The client on peritoneal dialysis who is complaining of a hard, rigid abdomen.

1 The tension headache does not involve nausea or vomiting but may involve photophobia or phonophobia. Since the nausea and vomiting are not expected, the nurse should return this phone call first.

The nurse in the neurological clinic is triaging phone calls. Which client should the nurse contact first? 1. The client with a tension headache who is reporting nausea and vomiting. 2. The client with a migraine headache who is reporting bilateral throbbing pain. 3. The client with a cluster headache who is reporting a sharp and stabbing pain. 4. The client with hypertension who is reporting pressure type pain in the back of head.

1, 2, and 3 are correct. 1. The UAP can escort the patient to the examination room and take the initial vital signs. 2. The UAP can weigh the patient and document the weight. 3. The UAP can clean the room and prepare it for the next patient.

The nurse in the outpatient clinic is working with an unlicensed assistive personnel (UAP). Which tasks are most appropriate for the nurse to delegate to the UAP? Select all that apply. 1. Take the client to the examination room and take the vital signs. 2. Weigh the client and document the weight in the client's chart. 3. Clean the room and set it up for the next client. 4. Discuss the prescriptions prescribed by the healthcare provider. 5. Call the pharmacy to authorize a refill on a client's prescription.

3 The UAP is attempting to move a client who weighs 400 pounds to the bedside commode. The UAP should request assistance to ensure client safety as well as to protect the UAP's back. This is a dangerous situation and requires intervention by the nurse.

The nurse in the rehabilitation unit is caring for clients along with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention? 1. The UAP assists a client 1 week postoperatively to eat a regular diet. 2. The UAP calls for assistance when taking a client to the shower. 3. The UAP is assisting the client who weighs 181 kg to the bedside commode. 4. The UAP places the call light within reach of the client who is sitting in the chair

3 The LPN can administer medications; therefore, the LPN could hang a bag of heparin on an IV pump to this client.

The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN? 1. Assess the client who will be transferred to the medical unit in the morning. 2. Administer a unit of blood to the client who is 1 day postoperative. 3. Hang the bag of heparin for a client diagnosed with a pulmonary embolus. 4. Assist the HCP with the insertion of a client's Swan-Ganz line.

2 The nurse should wash the area with soap and water and attempt to squeeze the area to make it bleed.

The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first? 1. Complete the accident/occurrence report. 2. Immediately wash the area with soap and water. 3. Ask the client whether he or she has AIDS or hepatitis. 4. Place an antibiotic ointment and bandage on the site.

3 Anticholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. This is the priority medication.

The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? 1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. 2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

1 The client with a closed head injury is at risk for increased intracranial pressure and the osmotic diuretic is a priority medication.

The nurse is administering medications on a neurological unit. Which medication should the nurse administer first? 1. The osmotic diuretic to the client with a closed head injury. 2. The morning medications to the client scheduled for physical therapy. 3. The narcotic pain medication to a client with increased intracranial pressure. 4. The anticonvulsant gabapentin (Neurontin) to the client with restless legs syndrome.

4 The client with hypothyroidism has a decreased pulse rate; therefore, the nurse should not administer a beta blocker, which could further decrease pulse rate. The client with thyrotoxicosis (hyperthyroidism) would receive Inderal. The nurse should question administering this medication.

The nurse is administering medications on an endocrinology unit. Which medication should the nurse question administering? 1. The propylthiouracil (PTU) to the client diagnosed with hyperthyroidism. 2. The desmopressin acetate (DDAVP) to the client diagnosed with diabetes insipidus. 3. The somatropin (Genotropin) to the client diagnosed with hypopituitarism. 4. The propranolol (Inderal) to the client diagnosed with hypothyroidism.

1 The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice.

The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.

3 The nurse should not administer an antiplatelet medication to a client going to surgery because this will increase postoperative bleeding. The nurse should hold this medication and discuss this with the surgeon.

The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering? 1. The loop-diuretic furosemide (Lasix) to a client who had a 320-mL output in 4 hours. 2. The anticoagulant enoxaparin (Lovenox) to a client who had open-heart surgery. 3. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery. 4. The ACE inhibitor captopril (Capoten) to a client who has a B/P of 100/68.

1 The client who is in pain is priority. None of the other clients have a life-threatening condition. Pain is considered the fifth vital sign.

The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first? 1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale. 2. The aminoglycoside antibiotic vancomycin intravenous piggyback (IVPB) to the client with an infected abdominal wound. 3. The proton-pump inhibitor pantoprazole (Protonix) IVPB to the client who is at risk for developing a stress ulcer. 4. The loop-diuretic furosemide (Lasix) intravenous push (IVP) to the client who has undergone surgical debridement of the right lower limb.

3 The bruises and burns should make the nurse suspect elder abuse, and the nurse is mandated by law to report this to Adult Protective Services.

The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arms. The client states she fell on an ashtray and doesn't want to talk about it. Which nursing intervention is priority? 1. Document the objective findings in the client's chart. 2. Tell the client she must talk about the situation with the nurse. 3. Report the situation to the Adult Protective Services. 4. Take photographs of the bruises and cigarette burns.

1 Aspirin, an antiplatelet agent, puts the client at risk for bleeding. The client diagnosed with deep vein thrombosis will be on warfarin (Coumadin), an anticoagulant, which puts the client at risk for bleeding; therefore, this comment requires immediate intervention by the nurse.

The nurse is admitting a client diagnosed with deep vein thrombosis (DVT) in the right leg. Which statement by the client warrants immediate intervention by the nurse? 1. "I take a baby aspirin every day at breakfast." 2. "I have ordered myself a medical alert bracelet." 3. "I eat spinach and greens at least twice a week." 4. "I got a new recliner so I can elevate my legs."

2 In order to treat the client with the most effective medication and not skew the results of a sputum culture, the specimen must be obtained prior to initiating antibiotics.

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider's order should be implemented first? 1. 1,000 mL normal saline at 125 mL/hour. 2. Obtain sputum for Gram stain and culture. 3. Ceftriaxone (Rocephin) 1,000 mg IVPB every 12 hours. 4. Ultrasonic nebulization treatment every 6 hours.

3 Cystic fibrosis (CF) is an inherited disease that causes thick, sticky mucus to form in the lungs, pancreas, and other organs. In the lungs, this mucus blocks the airways, causing lung damage and making it hard to breathe. A pulse oximeter reading of 90% equates to approximately a 60% arterial saturation. The nurse should assess this client first.

The nurse is assessing clients on a respiratory unit. Which client should be the nurse's first priority? 1. The client diagnosed with bronchiectasis who has clubbing of the fingernails. 2. The client diagnosed with byssinosis who reports chest tightness. 3. The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%. 4. The client diagnosed with pneumoconiosis who has shortness of breath.

2 Assessment of daily schedules and habits includes questions concerning hygiene practices, eating, elimination, sexual activity, sleep, work, exercise, and recreational activities.

The nurse is assessing the client's daily schedule and habits. Which question is most appropriate for the nurse to ask the client? 1. "Do you have a family member who can assist you when you go home?" 2. "What time do you prefer bathing and do you take a tub bath or a shower?" 3. "Do you have insurance to help with the cost of rehabilitation?" 4. "Do you have concerns about the care you are receiving here?"

4 Grade G indicates the client is dependent in all six functions including bathing, feeding, toileting, continence, dressing, and transferring. This client would require the nurse to delegate activities of daily living to the UAP.

The nurse is assessing the functional ability of a client using the Katz Index of Activities of Daily Living (ADLs). Which assessment grade would require the nurse to delegate feeding, bathing, and toileting to the unlicensed assistive personnel (UAP)? 1. Katz Index of ADLs grade A. 2. Katz Index of ADLs grade C. 3. Katz Index of ADLs grade E. 4. Katz Index of ADLs grade G.

Correct Answer: 5, 3, 1, 2, 4These are the best practices for helping a client use a cane when ambulating. 5. The gait belt is applied to ensure safety of the patient and the person assisting the client to ambulate. 3. The client should use the strong hand to control the assistive device. 1. The client should move the cane forward to provide a stable support for the weaker leg when it is moved. 2. The client should move the weaker leg even with the supportive cane while maintaining the stronger leg in place. 4. Finally, the stronger leg can move to a position even with the weak leg and cane.

The nurse is assisting the client to use a cane when ambulating. Rank in order of performance the interventions the nurse would take. 1. Request the client to move the cane forward. 2. Move the weaker leg one step forward. 3. Ensure the client places the cane in the strong hand. 4. Move the stronger leg one step forward. 5. Apply a gait's belt around the client's waist.

1 The nurse should implement the first intervention, ensuring the client does not move the leg, because doing so may cause further injury. The client should not attempt to move or stand on the injured extremity.

The nurse is at a local playground and her 10-year-old son falls and complains of his left ankle and foot hurting. Which intervention should the nurse implement first at the scene of the accident? 1. Instruct her son not to move the left leg. 2. Elevate the left leg on two rolled towels. 3. Apply an ice pack to the left ankle. 4. Check her son's pedal pulse bilaterally.

2 The nurse should first stabilize the foreign object to help prevent further damage. The stick should not be removed because it will cause more damage and possibly enucleate the eye.

The nurse is at a park and observes a client fall and a stick become impaled into the right eye. Which intervention should the nurse implement first? 1. Tell someone to call 911 immediately. 2. Stabilize the stick in the client's eye. 3. Apply direct pressure to the right eye. 4. Use a non-toxic liquid and irrigate the eye.

2 The nurse should determine if the woman has medication available that will save her life. If she doesn't, the nurse will have to wait for the ambulance.

The nurse is at the local mall and a young woman starts having shortness of breath, has hives on her face and arms, and is complaining of itching. Which intervention should the nurse implement first? 1. Tell a by-stander to call 911 immediately. 2. Ask the woman if she has an EpiPen. 3. Check the client for a medical alert bracelet. 4. Place a soft cushion under the client's head.

3 After two attempts, the nurse should arrange for a second nurse to attempt the placement.

The nurse is attempting to start an intravenous (IV) line in an elderly client who is dehydrated. After two unsuccessful attempts, which intervention should the nurse implement? 1. Keep trying to get a patent IV access. 2. Ask the HCP to order oral fluid replacement. 3. Ask a second nurse to attempt to start the IV. 4. Place cold packs on the client's arms for comfort.

4 The UAP can document the amount of food consumed on a calorie-count form for the dietician to evaluate.

The nurse is caring for a 14-year-old female client diagnosed with bulimia. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Talk with the parents about setting goals for the client. 2. Stay with the client for 15 to 20 minutes after each meal. 3. Encourage the client to verbalize low self-esteem. 4. List for the dietician the amount of food the client consumed.

1 The nurse should first determine if the client is hypovolemic prior to taking any other action. This will determine the nurse's next action.

The nurse is caring for a client 1 day postoperative sigmoid resection. There is a large amount of bright red blood on the dressing. Which intervention should the nurse implement first? 1. Assess the client's apical pulse and blood pressure. 2. Auscultate the client's bowel sounds. 3. Notify the healthcare provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1 and 2 are correct. 1. Checking the client's skin involves assessment; therefore, the nurse cannot delegate this assignment to the UAP. 2. The nurse cannot delegate medication administration to a UAP.

The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication. 3. Perform the client's morning hygiene care. 4. Ambulate the client to the bathroom. 5. Obtain the client's routine vital signs.

2 The UAP can clean the client's dentures, so this task should be delegated.

The nurse is caring for a client diagnosed with a full-thickness burn over the right lower extremity. Which task should the nurse delegate to the UAP? 1. Instruct the UAP to check the client's right dorsalis pedal pulse. 2. Ask the UAP to cleanse the client's dentures and place in the container. 3. Request the UAP to perform passive range-of-motion (ROM) exercises. 4. Tell the UAP to keep the client's right leg in the dependent position

2 After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse's first intervention

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.

4 Coffee ground emesis indicates bleeding and old blood, and warrants intervention by the nurse. Further assessment is needed to determine if the client is hypovolemic and the HCP should be notified.

The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse? 1. The client has hypoactive bowel sounds. 2. The client's output is 480 mL for 12-hour shift. 3. The client has T 98.6, AP 98, RR 22, B/P 102/78. 4. The client has coffee ground emesis.

3 The client should be referred to a psychological counselor to develop skills for coping with the long-term chronic illness.

The nurse is caring for a client newly diagnosed with multiple sclerosis. Which referral is appropriate at this time? 1. To a social worker to apply for disability. 2. To a dietician for a nutritional consult. 3. To a psychological counselor for therapy. 4. To a chaplain to discuss spiritual issues.

Correct Answer: 1, 4, 3, 2, 5 1. The nurse should begin the care by assessing the client. Remember the nursing process. 4. The nurse should have the client's chest and dressing exposed and should check to make sure the chest tube is securely taped at this time. 3. The nurse then follows the chest tube to the drainage system and assesses the system. 2. The last part of the chest tube drainage system to assess is the suction system. 5. The nurse should make sure that emergency supplies are at the bedside last.

The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside.

1, 3, and 4 are correct. The HCP must order the insertion of a Sengstaken-Blakemore tube, so this is a collaborative nursing intervention. This is a collaborative intervention that the nurse should implement. It requires an order from the HCP. Obtaining laboratory data requires an HCP's order, so this is a collaborative intervention.

The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Prepare to administer a Sengstaken-Blakemore tube. 2. Assess the client's vital signs. 3. Administer a proton-pump intravenously. 4. Obtain a type and crossmatch for four units of blood. 5. Monitor the client's intake and output.

4 The three-way indwelling catheter is placed during surgery to keep blood clots from remaining in the bladder and causing bladder spasms and increasing bleeding. The nurse should first assess the drainage system to make sure that it has not become obstructed with a clot.

The nurse is caring for an 84-year-old male client diagnosed with benign prostatic hypertrophy. The client has undergone a transurethral resection of the prostate (TURP) and is complaining of bladder spasms. Which intervention should the nurse implement first? 1. Administer an antispasmodic medication for bladder spasms. 2. Calculate the client's urinary output. 3. Palpate the client's abdomen for bladder distention. 4. Assess the client's three-way urinary catheter for patency.

2 When an elderly client's mental status changes, the nurse should notify the HCP because it is not normal or expected. This could indicate a urinary tract infection secondary to an indwelling catheter. Elderly clients often do not present with classic signs and symptoms of infection.

The nurse is caring for an elderly female client who has an indwelling catheter. Which data warrants notifying the healthcare provider? 1. The client's vital signs are T 98, AP 90, RR 16, B/P 142/88. 2. The client has had a change in her mental status. 3. The client's urine is cloudy with sediment. 4. The client has no discomfort or pain.

2 More than likely, this client has a urinary tract infection, which requires a midstream urinalysis. Of these four clients, this client should be seen first to have the test ordered.

The nurse is caring for clients in a family practice clinic. Which client should the nurse assess first? 1. The male client with chronic pyelonephritis who has costrovertebral tenderness. 2. The female client who is having burning and pain on urination. 3. The female client with urethritis who reports dysuria, urgency, and frequent urination. 4. The male client who has hesitancy, terminal dribbling, and intermittency.

1 The client diagnosed with Parkinson's disease who has begun to hallucinate may be experiencing an adverse reaction to one of the medications used to treat the disease. The nurse should assess this client first.

The nurse is caring for clients in a long-term care facility. Which client should the nurse assess first after receiving the morning report? 1. The client diagnosed with Parkinson's disease who began to hallucinate during the night. 2. The client diagnosed with congestive heart failure who has 3+ pitting edema of both feet. 3. The client diagnosed with Alzheimer's disease who was found wandering in the hall at 0200. 4. The client diagnosed with terminal cancer who has lost 8 pounds since the last weight taken 4 weeks ago.

4 The client with primary open-angle glaucoma reports no symptom of pain or pressure, so a client reporting eye pain warrants intervention by the nurse.

The nurse is caring for clients in an ophthalmology clinic. Which client warrants intervention by the nurse? 1. The client with cataracts who reports decreased vision and abnormal color perception. 2. The client with a retinal detachment who reports a painless loss of peripheral vision. 3. The client with an external hordeolum who reports reddened tender area under eye. 4. The client with primary open angle glaucoma who reports excruciating eye pain.

1 An epidural hematoma results from bleeding between the dura and the inner surface of the skull, and is a medical emergency. This client should be seen first.

The nurse is caring for clients in the emergency department. Which client should the nurse assess first? 1. The client with an epidural hematoma. 2. The client who had a seizure who is in the postictal state. 3. The client diagnosed with R/O encephalitis who has a headache. 4. The client with multiple sclerosis who has scanning speech.

1 Masseter rigidity is a sign of malignant hyperthermia, which is a life-threatening complication of surgery. The client will also exhibit tachycardia (a heart rate greater than 150 bpm), hypotension, decreased cardiac output, and oliguria. It is a rare muscle disorder chemically induced by anesthesia.

The nurse is caring for clients in the post-anesthesia care unit (PACU). Which client requires immediate intervention by the PACU nurse? 1. The client who had a bilateral adrenalectomy who is exhibiting masseter rigidity. 2. The client who had a subtotal thyroidectomy who has not urinated since surgery. 3. The client who had general anesthesia who is sleepy but arouses easily to verbal stimuli. 4. The client who had a pituitary tumor removed and has hypoactive bowel sounds.

3 This client has experienced a physiological problem and the nurse must assess the client and the emesis to decide on possible interventions.

The nurse is caring for clients on a medical unit. Which task should the nurse implement first? 1. Change the abdominal surgical dressing for a client who has ambulated in the hall. 2. Discuss the correct method of placing Montgomery straps on the client with the UAP. 3. Assess the male client who called the desk to say he is nauseated and just vomited. 4. Place a call to the extended care facility to give the report on a discharged client.

4 Nephrolithiasis, kidney stones, is characterized by pain and hematuria, but the nurse must assess the pain to determine whether a complication has occurred or it is the expected routine pain. Pain is the common priority of these four clients.

The nurse is caring for clients on a renal unit and making assignments for the day shift. Which client should the nurse assess first? 1. The client diagnosed with interstitial cystitis who has urinary urgency and pain in the bladder. 2. The client with acute post-streptococcal glomerulonephritis who has hematuria with a smoky appearance. 3. The client diagnosed with Goodpasture syndrome who has pallor, anemia, and renal failure. 4. The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain, rating it as a 9 on 1 to a 10 pain scale.

4 The client with acute pyelonephritis, an inflammation of the renal parenchyma and collecting system, is not expected to get dehydrated; therefore, this client should be assessed first.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? 1. The client diagnosed with polycystic kidney disease who has a B/P 170/100. 2. The client diagnosed with bladder cancer who has gross painless hematuria. 3. The client diagnosed with renal calculi who thinks he passed a stone. 4. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.

2 Pain is priority because the nurse must determine if this is expected postoperative pain or a complication of the surgery. This client should be assessed first.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO2 44, HCO3 30. 2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10. 3. The client who is 12 hours postoperative abdominal surgery and has dark green bile draining in the nasogastric tube. 4. The client who is 2 days postoperative for hiatal hernia repair and is complaining of feeling constipated.

1 Therapeutic levels for PTT should be 11/2 to 2 times the normal value, which is39 seconds; therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the facility protocol.

The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse? 1. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT). 2. The hemoglobin 11.4 for a client diagnosed with Raynaud's phenomenon. 3. The white blood cell (WBC) count of 11,000 for a client with a stasis venous ulcer. 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN).

2 Parasthesia (numbness and tingling) indicates a graft occlusion from the surgical procedure, which is a potentially life- threatening complication; therefore, this client should be assessed first.

The nurse is caring for clients on a vascular surgical floor. Which client should be assessed first? 1. The client who is 2 days postoperative right below-the-knee amputation who has phantom pain in the right foot. 2. The client who is 1 day postoperative abdominal aortic aneurysm who is complain- ing of numbness and tingling of both feet. 3. The client with superficial thrombophlebitis of the left arm who is complaining of tenderness to the touch. 4. The client with arterial occlusive disease who is complaining of calf pain when ambulating down the hall.

2 The client is stable and elevating the feet is an appropriate intervention for a client with venous problems; therefore, the UAP could feed this client.

The nurse is caring for clients on a vascular unit. Which nursing task is most appropriate to delegate to an unlicensed assistive personnel (UAP)? 1. Tell the UAP to obtain the glucometer reading of the client who is dizzy and lightheaded. 2. Request the UAP to elevate the feet of the client with chronic venous insufficiency. 3. Ask the UAP to take the vital signs of the client who has numbness of the right arm. 4. Instruct the UAP to administer a tap water enema to the client with an aorta aneurysm.

1 The unlicensed assistive personnel (UAP) can calculate intake and output for clients. The UAP cannot evaluate the numbers to determine if the treatment is effective, but the UAP can obtain the numbers.

The nurse is caring for clients on the renal unit. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to calculate the clients' urinary intake and output. 2. Request the UAP to double-check a unit of blood that is being administered. 3. Tell the UAP to change the surgical dressing on the client with a kidney transplant. 4. Ask the UAP to transfer the client from the renal unit to the intensive care unit.

3 A hypophysectomy is surgery that removes the pituitary gland by making an incision in the inner aspect of the upper lip and gingival. The sella turicica is entered through the floor of the nose and sphenoid sinuses. There are no visual incisions and the nose cannot be splinted.

The nurse is caring for the client who is 1 day postoperative transsphenoidal hypophysectomy. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP places the client with the HOB 30 degrees elevated. 2. The UAP tells the client not to cough vigorously. 3. The UAP is helping the client splint the incision. 4. The UAP is taking the client's vital signs.

2 The nurse would not expect the client with BPH to have oozing blood from the intravenous site. This may indicate disseminated intravascular coagulation (DIC), which is a potentially life-threatening complication and requires immediate intervention.

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with acute glomerulonephritis who has oliguria and periorbital edema. 2. The client with benign prostatic hypertrophy who has blood oozing from the intravenous site. 3. The client with renal calculi who is complaining of flank pain rated as a 5 on a scale of 1 to 10. 4. The client with nephrotic syndrome who has proteinuria and hypoalbuminemia.

2 This client was just transferred from the Post Anesthesia Care Unit (PACU); therefore, the nurse should assess this client first to perform a baseline assessment and ensure the client is stable.

The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? 1. The client with an inguinal hernia repair who has a urine output of 160 mL in 4 hours. 2. The client with an emergency appendectomy who was transferred from PACU. 3. The client who is 4 hours postoperative abdominal surgery who has flatulence. 4. The client who is 6 hours post-procedure colonoscopy and is being discharged.

Correct Answer: 3, 1, 4, 5, 2 3. The nurse should first put on non-sterile gloves, due to body fluid contamination. 1. The nurse should remove the bag care- fully and ensure no drainage in the bag gets on the client's skin. 4. The nurse should ensure the stoma site is moist and pink. 5. The area around the stoma should be cleansed with soap and water and allowed to dry thoroughly. 2. Lastly, the nurse should apply the new colostomy bag.

The nurse is changing the client's colostomy bag. Which interventions should the nurse implement? Rank in the order of priority. 1. Remove the client's colostomy bag. 2. Apply the client's new colostomy bag. 3. Don non-sterile gloves. 4. Assess the client's stoma site. 5. Cleanse the area around the client's stoma.

3 According to the NSCBN NCLEX-RN® test plan, collaboration with interdisciplinary team members is part of the management of care. The nurse should first consult with the pharmacist to determine whether the client is taking any medications that could interact with the saw palmetto.

The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, "I am taking saw palmetto for my enlarged prostate." Which intervention should the nurse implement first? 1. Notify the client's HCP to write an order for the herbal supplement. 2. Ask the client why he is taking an herb for his enlarged prostate. 3. Consult with the pharmacist to determine any potential drug interactions. 4. Look up saw palmetto in the Physicians' Desk Reference (PDR).

4 The staff nurse should be a part of the solution to a problem; volunteering to be on a committee of peers is the best action to effect a change.

The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. Which action is most appropriate for the nurse to implement first? 1. Discuss the blood administration flow sheet with the chief nursing officer. 2. Contact an individual to help design a new blood transfusion flow sheet. 3. Learn to adapt to the present form and do not take any further action. 4. Volunteer to be on an ad hoc committee to research alternate flow sheets.

4 Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

The nurse is developing a nursing care plan for the client diagnosed with chronic kidney disease. Which nursing problem should be addressed first? 1. Self-care deficit. 2. Knowledge deficit. 3. Chronic pain. 4. Excess fluid volume.

1, 2, and 4 are correct. 1. Acupuncture is traditional Chinese medicine, which involves the use of sharp, thin needles that are inserted in the body at very specific points and is believed to adjust and alter the body's energy flow into healthier patterns. 2. Guided imagery is the use of relaxation and mental visualization to improve mood and/or physical well-being. 4. Music therapy is a technique of complementary alternative medicine that uses music prescribed in a skilled manner by trained therapists. Programs are designed to help patients overcome physical, emotional, intellectual, and social challenges.

The nurse is discussing alternative medication (CAM) with a client on the rehabilitation unit. Which therapies should the nurse discuss with the client? Select all that apply. 1. Acupuncture. 2. Guided imagery. 3. Compression sequential devices. 4. Music therapy. 5. Muscle-strengthening exercises.

4 The nurse is specifically describing the term "durable power of attorney for healthcare." It is a document included in an advance directive.

The nurse is discussing end-of-life issues with a client. The nurse is explaining about a document used for listing the person the client will allow to make healthcare decisions should he or she become unable to make informed decisions for him- or herself. Which document is the nurse discussing with the client? 1. Advance directive. 2. Directive to physicians. 3. Living will. 4. Durable power of attorney for healthcare.

2 Betadine is included in the indwelling catheter kit; so another form of cleaning agent must be used when inserting the catheter. Therefore, this is the first intervention.

The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first? 1. Ask the client if he has any prostate problems. 2. Determine if the client has any betadine allergies. 3. Lubricate the end of the indwelling catheter. 4. Ensure urine is obtained in the indwelling catheter.

1 The client's catheter should be secured on the leg to prevent manipulation, which increases the risk for a urinary tract infection. This warrants immediate intervention by the nurse.

The nurse is observing the unlicensed assistive personnel (UAP) provide care to a client with an indwelling catheter. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP does not secure the tubing to the client's leg with tape. 2. The UAP wears gloves when providing catheter care to the client. 3. The UAP positions the collection bag on the side of the client's bed. 4. The UAP cares for the client's catheter after washing his or her hands.

Correct Answer: 3, 2, 1, 4, 5. 3. The nurse must first assess the drainage in the bag for color, consistency, and amount. 2. After removing the bag, the nurse should assess the site to ensure circulation to the stoma. A pink, moist appearance indicates adequate circulation. 1. The nurse should cleanse the area with a mild soap and water to ensure that the skin is prepared for the adhesive paste. 4. The nurse should then apply adhesive paste to the clean, dry skin. 5. The ostomy drainage bag is attached last.

The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority. 1. Cleanse the stomal site with mild soap and water. 2. Assess the stoma for a pink, moist appearance. 3. Monitor the drainage in the ostomy drainage bag. 4. Apply stoma adhesive paste to the skin around the stoma. 5. Attach the ostomy drainage bag to the abdomen.

2 Altered mobility is a problem experienced by clients diagnosed with Parkinson's disease. It leads to many other concerns, including the risk for falls resulting from the client's shuffling gait. This is the priority problem.

The nurse is planning care for the client diagnosed with Parkinson's disease (PD). Which client problem is priority? 1. Altered nutrition. 2. Altered mobility. 3. Altered elimination. 4. Altered body image.

4 Fluid and electrolyte imbalance can cause cardiac dysrhythmias. This is the priority problem.

The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? 1. Altered nutrition. 2. Self-care deficit. 3. Impaired body image. 4. Fluid and electrolyte imbalance.

2 The test is a barium study of the upper GI system and requires the client's upper GI system to be empty. This client should be made NPO at least 8 to 10 hours before the test.

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fluid intake after the procedure. 3. Explain to the client that he or she will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure.

3 The location of the incision for a cholecystectomy, the general anesthesia needed, and a heavy smoking history make this client high risk for pulmonary complications.

The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abdominal mass who is overweight. 2. The client scheduled for a gastrectomy who has arterial hypertension. 3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day. 4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis.

Correct Answer: 3, 2, 1, 4, 5 3. The client must agree to the risks and benefits of a blood transfusion before the nurse can administer the blood product. This is the first intervention.2. The nurse has only 30 minutes from the time the blood is retrieved from the blood bank until the transfusion is initiated. The nurse should make sure the client has a patent IV access before obtaining the blood from the blood bank. 1. The nurse can obtain the unit of packed cells when the client has signed the permit and has a patent IV access. 4. The nurse should always check the blood product with another nurse at the client's bedside against the client's hospital identification band and blood bank crossmatch band. 5. After the nurse has followed the procedure to ensure the correct blood product is being administered, with a second nurse then the transfusion of packed cells can be initiated. The blood is initiated at a slow rate—10 mL per hour for the first 15 minutes—so that the nurse can observe the client for potential complications.

The nurse is preparing to administer a unit of packed red blood cells to an elderly client who is 1 day postoperative abdominal aortic aneurysm. Which interventions should the nurse implement? List in order of performance. 1. Obtain the unit of blood from the blood bank. 2. Start an IV access with normal saline at a keep-open rate. 3. Have the client sign the permit to receive blood products. 4. Check the unit of blood with another nurse at the bedside. 5. Initiate the transfusion at a slow rate for 15 minutes.

4 Ensuring the site is patent is the first intervention because even if it is the correct client, the medication should not be administered if the IV site is infiltrated.

The nurse is preparing to administer intravenous narcotic medication to the client who has renal calculi and is complaining of pain rated as 8 on 1 to 10 pain scale. The client's vital signs are stable. Which intervention should the nurse implement first? 1. Clamp the IV tubing proximal to the port of medication administration. 2. Administer the narcotic medication slowly over 2 minutes. 3. Check the medication administration record (MAR) against the hospital identification band. 4. Determine if the client's intravenous site is patent.

4 The client is describing symptoms of hyperthyroidism. Because the client is diagnosed with hypothyroidism, has been prescribed thyroid hormone replacement, and now has symptoms of hyperthyroidism, it can be assumed that the client now has an excess of thyroid hormone. Therefore, the nurse should hold the thyroid medication and check the client's thyroid profile.

The nurse is preparing to administer medications for clients on a medical unit. The client diagnosed with hypothyroidism is complaining of being hot all the time, feeling palpations, and being jittery. Which intervention should the nurse implement first? 1. Check the client's serum thyroid levels. 2. Assess the client for diarrhea. 3. Document the finding in the chart. 4. Hold the client's thyroid medication.

4 Tylenol is administered for mild- to-moderate pain. By the time the nurse obtains the medication and performs all of the steps to administer a medication correctly, it will be time for the client to receive the Tylenol. This medication should be administered first.

The nurse is preparing to administer medications. Which medication should the nurse administer first? 1. Digoxin (Lanoxin), a cardiac glycoside, due at 0900. 2. Furosemide (Lasix), a loop diuretic, due at 0800. 3. Propoxyphene (Darvon), an analgesic, due in 2 hours. 4. Acetaminophen (Tylenol), an analgesic, due in 5 minutes.

4 The client with urticaria (hives) and pruritus (itching) is having some type of allergic reaction and should receive the antihistamine first.

The nurse is preparing to administer morning (a.m.) medications to the following clients. Which medication should the nurse administer first? 1. The NSAID to the client diagnosed with osteoarthritis. 2. The intravenous antibiotic to the client with cellulitis. 3. The antiviral agent to the client with herpes zoster (shingles). 4. The antihistamine to the client with urticaria and pruritus.

3 A mucosal barrier agent must be administered before the client eats in order for the medication to coat the gastric mucosa. This medication should be administered first.

The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first? 1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn's disease. 2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia. 3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease. 4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery.

2 Insulin should be administered before a meal for best effects. This medication should be administered first.

The nurse is preparing to administer morning medications. Which medication should the nurse administer first? 1. The levothyroxine (Synthroid), a thyroid hormone, to a client diagnosed with hypothyroidism. 2. The Humulin N insulin, a pancreatic hormone, to a client diagnosed with type 2 diabetes. 3. The prednisone, a glucocorticoid, to a client diagnosed with Addison's disease. 4. The tiotropium (Spiriva) inhaler, a bronchodilator, to a client diagnosed with chronic asthma.

2 The nurse's priority is to ensure the safety of the client, and placing a safety gait belt around the client's waist before ambulating the client helps to ensure safety. The gait belt provides a handle to hold onto the client securely during ambulation.

The nurse is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement? 1. Place rubber-soled shoes on the client. 2. Put a gait belt around the client's waist. 3. Explain the procedure to the client. 4. Provide a clear path for the client to walk.

4 Dressing changes for a Stage III pressure ulcer will be painful for the client and the nurse should make sure the client has received pain medication at least 30 minutes prior to the procedure. This is showing client advocacy.

The nurse is preparing to change a dressing on an 82-year-old client with a Stage III pressure ulcer. Which intervention should the nurse implement first? 1. Obtain the needed equipment to perform the procedure. 2. Remove the client's old dressing with nonsterile gloves. 3. Explain the procedure to the client in understandable terms. 4. Check to determine whether the client has received pain medication.

2 Patients diagnosed with deep vein thrombosis are at risk for pulmonary embolism (PE). Anxiety is a symptom of PE. The nurse must determine if interventions are needed for PE, a life-threatening emergency.

The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first? 1. The patient diagnosed with end-stage COPD complaining of shortness of breath after ambulating to the bathroom. 2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication. 3. The patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the laboratory. 4. The patient diagnosed with an empyema who has a temperature of 100.8°F, pulse of 118, respiration rate of 26, and BP of 148/64.

3 This is a private moment and should be respected by the nurse. The nurse should allow the client and spouse quiet time together.

The nurse is preparing to perform a dressing change on a female client who has end-stage renal disease. The nurse notes the client's husband is silently holding the client's hand and praying. Which action should the nurse implement first? 1. Continue to prepare for the dressing change in the room. 2. Call the chaplain to help the client and spouse pray. 3. Quietly leave the room and come back later for the dressing change. 4. Ask the husband whether or not he would like the nurse to join in the prayer.

1 This is an example of meditation.

The nurse is providing complementary alternative medicine (CAM) by teaching the client with hyperthyroidism to focus attention, increase self-awareness, and increase concentration on an object. Which type of mind-body intervention is the nurse teaching? 1. Meditation. 2. Imagery. 3. Aromatherapy. 4. Acupressure.

3 The nurse should first ensure a patent airway. According to Maslow's Hierarchy of Needs, airway is always priority.

The nurse is the first person on the scene of a motor vehicle accident. The driver is in the driver's seat unconscious. Which action should the nurse implement first? 1. Stabilize the driver's cervical spine. 2. Do not move the client from the accident. 3. Ensure the driver has a patent airway. 4. Control any external bleeding.

2 Allergic contact dermatitis occurs when skin comes in contact with an allergen the client is sensitive or allergic to. Symptoms include redness, swelling, blistering, itching, and weeping. This client has an acute dermatological condition and should be seen immediately

The nurse is triaging phone calls in a dermatological clinic. Which client warrants the nurse making an appointment immediately? 1. The client reports having white spots on both of the hands. 2. The client reports redness and itching on the hands. 3. The client reports a cherry angioma on the right lower leg. 4. The client reports red patches on one side of the body.

2 This is priority because the safety of the client must be ensured. If the client is not placed correctly in the lift sleeve, the client could fall. Electric lifts are powered either through a standard electrical outlet or by a rechargeable battery. The lifting is completely controlled through a hand control, eliminating any physical exertion by the caregiver.

The nurse is using an electric patient "Hoyer" lift to transfer the client from the bed to a stretcher. Which priority intervention should the nurse implement? 1. Have two staff members assist when using the lift. 2. Ensure the client is correctly placed in the lift prior to moving. 3. Lift the client slowly off the bed when turning on the lift. 4. Ensure the stretcher is in the correct position and locked.

3 The UAP can obtain the client's height and weight. This is the task the nurse should delegate.

The nurse is working in a community health clinic. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to take the client's history. 2. Request the UAP to document the client's complaints. 3. Ask the UAP to obtain the client's weight and height. 4. Tell the UAP to complete the client's follow-up care.

4 The client diagnosed with pheochromocytoma, a tumor of the adrenal medulla that produces excessive catecholamine, is expected to have a severe pounding headache and chest pain; but of these four clients this client is having pain, which is priority. This client warrants intervention by the nurse.

The nurse is working in an endocrinology unit. Which client warrants immediate intervention by the nurse? 1. The client with acromegaly who has club-like fingertips and large feet. 2. The client with syndrome of inappropriate antidiuretic hormone who has decreased urine output. 3. The client with Cushing's syndrome who has truncal obesity and thin, fragile skin. 4. The client with pheochromocytoma who has a severe pounding headache and chest pain.

3 Numbness and tingling of the legs are signs of possible neurovascular compromise. This client should be assessed first.

The nurse is working in an orthopedic unit. Which client should the nurse assess first? 1. The client who is 2 weeks postoperative open reduction and external fixation (ORIF) of the right hip who is complaining of pain when ambulating. 2. The client who is 10 days postoperative for left total knee replacement (TKR) who is refusing to use the continuous passive motion (CPM) machine. 3. The client who is 1 week postoperative for L3-L4 laminectomy who is complaining of numbness and tingling of the feet. 4. The client who is being admitted to the rehabilitation unit from the orthopedic surgical unit after a motor vehicle accident (MVA).

4 These are signs of an acute transplant rejection, which is potentially a life-threatening problem; therefore, the nurse should notify the healthcare provider about this client

The nurse is working in an outpatient clinic triaging phone calls. Which client warrants notifying the healthcare provider? 1. The client with type 2 diabetes receiving hemodialysis who has gained 6 pounds since the last dialysis treatment. 2. The client with type 1 diabetes who has early stage chronic renal disease and reports having to go to the bathroom several times at night. 3. The client with syndrome of inappropriate antidiuretic hormone who is very upset because no one has returned the previous phone call. 4. The client with type 1 diabetes who had a kidney transplant and reports decreased urine output and flu-like symptoms.

3 The nurse cannot delegate or assign tasks that require nursing judgment, such as evaluating a client's progress.

The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients. 2. The bed baths and oral care. 3. Evaluating the client's progress. 4. Transporting a client to dialysis.

1 This client is experiencing neurovascular compromise and requires immediate attention. The client with venous problems should have palpable pedal pulses. This procedure is for clients with varicose veins.

The nurse just received the a.m. shift report. Which client should the nurse assess first? 1. The client who is 6 hours post-op vein ligation who has absent pedal pulses. 2. The client diagnosed with deep vein thrombosis who is complaining of calf pain. 3. The client with Raynaud's disease who has throbbing and tingling in the extremities. 4. The client with Buerger's disease who has intermittent claudication of the feet and arms.

1 The LPN can administer medication to the client; therefore, this is an appropriate assignment.

The nurse manager in the medical-surgical outpatient clinic is making assignments. Which task is most appropriate to delegate/assign to the UAP/LPN? 1. Ask the LPN to administer the flu vaccine to the client. 2. Tell the UAP to call the pharmacist to refill a prescription. 3. Request the LPN to obtain the height and weight of the client. 4. Instruct the UAP to empty the trashcans in the clients' rooms.

4 The XL in the name of the medication indicates that this medication is a sustained-released formulation and should not be crushed. The nurse should speak directly with the LPN to correct the behavior.

The nurse observes an LPN crushing nifedipine (Procardia XL) before administering the medication to a client with arterial hypertension who has difficulty swallowing pills. Which intervention should the nurse implement first? 1. Tell the LPN to take the client's blood pressure. 2. Take no action since this is appropriate behaviour. 3. Show the LPN where to find pudding for the client. 4. Tell the LPN this medication cannot be crushed.

2 The nurse should remove the LPN from the situation without embarrassing the LPN. Asking the LPN to come to the office area is the appropriate action for the nurse to take. The LPN's action is a violation of HIPAA.

The nurse observes an LPN discussing an intravenous pyleogram, a diagnostic test, with a client in the waiting room of the outpatient clinic. Which action should the nurse implement? 1. Praise the LPN for talking to the client about the diagnostic test. 2. Tell the LPN the nurse needs to talk to her in the office area. 3. Go to the waiting room and tell the LPN not to discuss this there. 4. Inform the HCP that the LPN was talking to the client in the waiting room.

2 The UAP is able to obtain a urine specimen from the client. This task is not assessment, teaching, evaluation, medications, or the care of an unstable client.

The nurse on the endocrinology unit is caring for clients, assisted by an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP? 1. Feed the client who is 1 day postoperative transsphenoidal hypophysectomy. 2. Obtain a urine specimen for the client diagnosed with diabetes insipidus. 3. Take the vital signs for the client diagnosed with myxedema coma. 4. Assess the pulse oximeter reading of the client with an Addisonian crisis.

2 Metformin must be held 24 hours after a client has received any type of contrast dye, since it can cause renal failure. This medication should be questioned by the nurse.

The nurse on the medical unit is preparing to administer 0900 medications. Which medication should the nurse question administering? 1. The hormone levothyroxine (Synthroid) to the client diagnosed with hypothyroidism. 2. The metformin (Glucophage) to the type 2 diabetic who just had a CT scan with dye. 3. The Humulin N insulin to the client with type 1 diabetes who is no longer NPO. 4. The steroid prednisone to a client diagnosed with Addison's disease.

1 Nonmalfeasance is the duty to prevent or avoid doing harm. The nurse asking not to be assigned to the NICU because of lack of experience in caring for critically ill infants is supporting the ethical principle of nonmalfeasance.

The nurse on the surgical unit is being sent to the neonatal intensive care unit (NICU) to work because the unit is short staffed. The nurse has never worked in the NICU. Which response by the nurse supports the ethical principle of nonmalfeasance? 1. The nurse requests not to be floated to the NICU. 2. The nurse accepts the assignment to the NICU. 3. The nurse asks why another nurse can't go to the NICU. 4. The nurse talks another nurse into going to the NICU.

4 The UAP can escort the client to the vehicle after discharge.

The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? 1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client's IV insertion site on the right arm. 3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client's vehicle.

2 This comment warrants immediate intervention because the client's legs have decreased sensation secondary to the arterial occlusive disease, and a heating pad could burn the client's legs without the client's realizing it. The client should not use a heating pad to keep the legs warm.

The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants immediate intervention by the nurse? 1. "My legs start to hurt when I walk to check my mail." 2. "My legs were so cold I had to put a heating pad on them." 3. "I hang my legs off the side of my bed when I sleep." 4. "I noticed that the hair on my feet and up my leg is gone."

1 This is the reason for referring a client to a vocational counselor.

The nurse tells the client, "I am going to refer you to the vocational counselor." The client asks the nurse, "Why are you making this referral?" Which statement is the nurse's best response? 1. "The counselor will assist you with job placement, training, or further education." 2. "The counselor specializes in rehabilitative medicine and will help you get better." 3. "The counselor will help develop your fine motor skills to help perform ADLs." 4. "The counselor will help you continue or develop hobbies or interests."

2 The client with spinal surgery should be logrolled with at least two if not three staff members assisting with the turning from side to side. Logrolling the client ensures proper body alignment. Asking the client to turn would warrant intervention by the nurse.

The nurse tells the unlicensed assistive personnel (UAP) to assist the client who is 1day postoperative spinal surgery with a.m. care. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain. 2. The UAP requests the client to turn to the side. 3. The UAP checks the temperature of the bathing water. 4. The UAP puts the side rails up when bathing the client.

1 Clients receiving hospice can decide to discontinue the service and resume standard healthcare practices and treatments whenever they wish. The nurse should assess the client's wishes before continuing.

The nursing staff confronts the hospice nurse overseeing the care of a client in a long- term care facility. The nursing staff wants to send the client who is diagnosed with gangrene of the left leg secondary to peripheral occlusive disease to the hospital for treatment. Which intervention should the nurse implement first? 1. Check with the client to see whether or not the client wants to go to a hospital. 2. Explain that the client can be kept comfortable at the long-term care facility. 3. Discuss the hospice concept of comfort measures only with the staff. 4. Call a client care conference immediately to discuss the conflict.

3 The procedure for tornados is to have all clients, staff, and visitors stay in the hallway and close the doors to all the rooms. This will help prevent any flying debris or glass from hurting anyone

The overhead page has issued a Code Black, indicating a tornado in the area. Which intervention should the charge nurse implement? 1. Instruct the hospital staff to assist the clients and visitors to the cafeteria. 2. Request the client and visitors go into the bathroom in the client's room. 3. Have the clients and visitors remain in the hallway with the doors closed. 4. Tell the client and any visitors to remain in the client's room with the door open.

3 The first action in a Code Red (actual fire) is to Rescue (R) the clients in immediate danger, followed by confine (C), closing the doors. Doors in a hospital must be fire rated to confine a blaze for an hour and a half.

The overhead page has just announced a Code Red, actual fire, on a unit two floors below the unit where the nurse is working. Which action should the nurse implement first? 1. Turn off the oxygen supply to the rooms. 2. Evacuate the clients to a lower floor. 3. Close all of the doors to the clients' rooms. 4. Make a list of clients to discharge.

4 This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client.

The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic.

4 The nurse should stop the conversation immediately, and asking the UAP to go to the nurse's station does not embarrass the UAP. Gossiping about another client is a violation of his or her privacy, and a breach of protected health information under HIPAA.

The primary nurse overhears the unlicensed assistive personnel (UAP) telling a family member of a client, "One of the clients will be going to prison because that person was charged with vehicular manslaughter. Two people in the motor vehicle accident died." Which action should the primary nurse implement first? 1. Apologize to the family member for the UAP's comments. 2. Tell the UAP that the comment is a violation of HIPAA. 3. Allow the UAP to complete the conversation and then discuss the situation. 4. Interrupt the conversation and tell the UAP to go to the nurse's station.

4 The nurse can talk to anyone the client requests. This is not a violation of HIPAA as long as the client gives permission for the nurse to share information.

The rehabilitation nurse enters the client's room and the client is talking on the phone. The client asks the nurse to talk to his wife because she has some questions. Which action should the nurse take? 1. Explain that HIPAA regulations prevent the nurse from talking to the wife. 2. Tell the client it would be best for the nurse to talk to the wife in person. 3. Request the client's wife to come to the weekly team meeting to ask questions. 4. Honor the client's request and answer any questions the wife has on the phone.

4 The client is being discharged. The nurse should plan for continuity of care by arranging for a home health agency to follow the client at home.

The rehabilitation nurse is planning the discharge of a 68-year-old client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. Which referral should the nurse initiate at this time? 1. Referral to a hospice organization. 2. Referral to the speech therapist. 3. Referral to the physical therapist. 4. Referral to a home health agency.

4 The client is recovering from a potentially debilitating disease, and in the rehabilitation unit the client should be out of the bed as much as possible. Bathing the client in bed would warrant intervention by the nurse.

The rehabilitation nurse tells the unlicensed assistive personnel (UAP) to assist the client recovering from Guillain-Barré syndrome with a.m. care. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain. 2. The UAP massages the client's back with lotion. 3. The UAP checks the temperature of the bathing water. 4. The UAP puts the side rails up when bathing the client.

1, 2, and 3 are correct. 1. An antibiotic ointment, such as Polysporin, should be applied thinly four times daily. Polysporin can be purchased without a prescription. 2. Children should be kept home from school until the lesions crust over. 3. Use separate towels for the client. The client's towels, pillowcases, and sheets should be changed after the first day of treatment. The clothing should be changed and laundered daily for the first 2 days.

The school nurse notes the child has impetigo. Which interventions should the nurse implement? Select all that apply. 1. Administer an antibiotic ointment four times a day. 2. Instruct the parents to keep the child at home until lesions crust over. 3. Tell the parents to use separate towels for the child. 4. Do not remove the crusts from the skin lesions. 5. Tell the parents to have the child wear non-latex sterile gloves over both hands until no crusting is present.

2 This is the definition of bereavement counseling.

The significant other of a client diagnosed with liver cancer and who is dying asks the nurse, "What is bereavement counseling?" Which statement is the nurse's best response? 1. "Bereavement counseling helps the client accept the terminal illness." 2. "It provides support to you and your family in the transition to a life without your loved one." 3. "We provide counseling to you and your loved one during the dying process." 4. "It is group counseling for family members whose loved ones have died."

1 The actions of the colleague indicate possible drug or alcohol impairment. The staff nurse is not in a position of authority to require the potentially impaired nurse to submit to a drug test. The administrative supervisor should assess the situation and initiate the appropriate follow-up. The nurse must make sure an impaired nurse is not allowed to care for clients.

The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. Which action should be taken by the nurse? 1. Ask the supervisor to come to the unit. 2. Determine what is bothering the nurse. 3. Suggest the nurse go home. 4. Smell the nurse's breath for alcohol.

1 The nurse should administer the IVP narcotic pain medication even if the client has shallow breathing, with respirations of 8. A nurse should never administer a medication with the intent of hastening the client's death, but medicating a dying client to achieve a peaceful death is an appropriate intervention.

The terminally ill client diagnosed with ALS (Lou Gehrig's disease) has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? 1. Administer the narcotic pain medication IVP. 2. Turn and reposition the client for comfort. 3. Refuse to administer pain medication. 4. Notify the HCP of the client's vital signs.

1 The manager should assess the abilities of each staff member for the needs of the unit before deciding which staff member to transfer.

The unit manager of an endocrinology unit is over budget for the year and must transfer one staff member to another unit. Which option is the best action for the unit manager to take before deciding which staff member to transfer? 1. Assess each staff member's abilities. 2. Choose the last staff member hired. 3. Ask for input from the staff members. 4. Request the transfer documentation form

4 The nurse's care is being evaluated, including the nurse's documentation. The completeness of documentation should be included in the evaluation.

The unit manager on the renal unit is evaluating the staff nurse. Which data should be included in the nurse's yearly evaluation? 1. The fact that the nurse clocked in late to work twice in the last year. 2. The complaint stating the nurse did not answer a call light during a code. 3. The number of times the nurse switched shifts with another nurse. 4. The appropriateness of the nurse's written documentation in the charts.

1 The change process can be compared to the nursing process. The first step of each process is to assess the problem. Assessment involves collecting the pertinent data that support the need for a change.

The unit manager on the vascular unit is planning a change in the way post-mortem care is provided. Which is the first step in the change process? 1. Collect data. 2. Identify the problem. 3. Select an alternative. 4. Implement a plan.

2 When the UAP gives information to the nurse about a client, the nurse must first assess the client prior to taking any action.

The unlicensed assistive personnel (UAP) has just taken the blood pressure of a client who had a thyroidectomy. The UAP tells the nurse that the client's hand turned into a claw when the blood pressure was taken. Which intervention should the nurse implement first? 1. Prepare to administer intravenous calcium gluconate. 2. Assess the client for signs/symptoms of hypoparathyroidism. 3. Request the UAP to elevate the client's head of the bed. 4. Notify the client's healthcare provider immediately.

3 Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest. Having the client elevate the legs before placing the stockings on the legs indicates that the UAP understands the procedure for applying the elastic compression stockings.

The unlicensed assistive personnel (UAP) is applying elastic compression stockings to the client. Which action by the UAP indicates to the nurse the UAP understands the correct procedure for applying the elastic compression stockings? 1. The UAP applies the stockings while the client is sitting in a chair. 2. The UAP is unable to insert two fingers under the proximal end of the stocking. 3. The UAP had the client elevate the legs prior to putting on the stockings. 4. The UAP places the toe opening of the elastic stocking on top of the client's foot.

4 The client should have a podiatrist cut his or her toenails. The unlicensed assistive personnel (UAP) should not do this because if the UAP accidently cuts the skin, it could cause a sore that may not heal, and then result in amputation of the extremity.

The unlicensed assistive personnel (UAP) is caring for a client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. The UAP assists the client to apply compression stockings. 2. The UAP elevates the client's leg while sitting in the recliner. 3. The UAP assists the client to the bathroom for a.m. care. 4. The UAP is cutting the client's toenails after soaking the client's feet in tepid water.

Correct Answer: 2, 5, 3, 4, 1 2. The wheelchair should be ready for the client to transfer to and is the first step. 5. The brakes should be locked so the chair will not move during the transfer. 3. The client should support him- or herself when moving with the stronger side. 4. The client next shifts the weight forward so he/she can pivot into the chair. 1. The client should not attempt until he/she feels the chair on the back of the legs so the client knows where the chair is.

The unlicensed assistive personnel (UAP) is transferring the client from the bed to the chair. Which interventions should the nurse ensure the UAP implements during this procedure? Rank in order of priority. 1. Assist the client to sit when the client's legs touch the edge of the chair. 2. Place the wheelchair at an angle on the client's strong side. 3. Assist the client to stand and put strong hand on the wheelchair armrest. 4. Keep the client's weight forward and pivot the client. 5. Lock the wheelchair brakes and secure the chair position.

2 This is the first action for the charge nurse. The client is preparing to leave, and a delay in going to the client's room could result in the client leaving before the situation can be resolved.

The unlicensed assistive personnel (UAP) notifies the charge nurse that the male client is angry with the care he is receiving and is packing to leave the hospital. Which intervention should the charge nurse implement first? 1. Ask the client's nurse why the client is upset. 2. Discuss the problem with the client. 3. Notify the healthcare provider (HCP). 4. Have the client sign the against medical advice (AMA) form.

2 The nurse should praise the UAP for taking the initiative and placing the client in the prone position. The prone position will help prevent contractures of the residual limb, which will make it easier to apply a prosthetic device.

The unlicensed assistive personnel (UAP) on the rehabilitation unit is placing the client with a left above-the-knee amputation in the prone position. Which action should the nurse implement? 1. Tell the UAP to place the client on the back. 2. Praise the UAP for positioning the client prone. 3. Report this action verbally to the charge nurse. 4. Explain to the UAP that the client should not be placed on the stomach.

3 The nurse must first assess the UAP's findings and the client before taking any further action.

The unlicensed assistive personnel (UAP) reports to the nurse the client's urine output has bright red blood. Which intervention should the nurse implement first? 1. Instruct the UAP to take a urine specimen to the laboratory. 2. Document the findings in the client's nursing notes. 3. Assess the client's urine specimen and complete a renal assessment. 4. Ask the UAP to take the client's vital signs.

3 This is the first intervention because the nurse must assess the client. Asking the UAP to accompany the nurse will allow the nurse to stay with the client while the UAP obtains any needed equipment.

The unlicensed assistive personnel (UAP) tells the clinic nurse that the male client in Room 1 is "really breathing hard and can't seem to catch his breath." Which instruction should the nurse give to the UAP? 1. Put 4 mL oxygen on the client. 2. Sit the client upright in a chair. 3. Go with the nurse to the client's room. 4. Take the client's vital signs.

3 The first part of the nursing process is assessment. The nurse must first assess the client's pain to determine if the pain indicates a complication requiring medical intervention, or if this is routine postoperative pain, which is expected.

The unlicensed assistive personnel (UAP) tells the nurse a female client, who had a laparoscopic cholecystectomy, is complaining of abdominal pain. Which intervention should the nurse implement first? 1. Check the medication administration record for the last pain medication the client received. 2. Instruct the UAP to ask the client to rate her pain on a 1 to 10 pain scale. 3. Assess the client to rule out any postoperative surgical complications. 4. Tell the UAP to obtain the client's vital signs and pulse oximeter reading.

1 The nurse should first appraise the situation and not do anything. This is the pivotal point at which the nurse can return the anger or reappraise the situation. The most important action to take is to empathize with the UAP and to try to find out the provocation for the behavior.

The unlicensed assistive personnel (UAP) tells the nurse angrily, "You are the worst nurse I have ever worked with and I really hate working with you." Which action should the nurse implement first? 1. Don't respond to the comment and appraise the situation. 2. Tell the UAP to leave the unit immediately. 3. Report this comment and behavior to the charge nurse. 4. Explain to the UAP that he or she cannot talk to the primary nurse like this.

2 A chaplain is a spiritual adviser who can stay with the client until a family member or the client's personal spiritual adviser can come to the hospital to be with the client.

The unlicensed assistive personnel (UAP) tells the nurse that a client is crying and upset because she has been told her husband has just died. Which intervention should the nurse implement? 1. Tell the UAP to go and sit with the client. 2. Make a referral for the chaplain to see the client. 3. Ask the HCP to prescribe a mild sedative. 4. Leave the client alone in the room to grieve.

3 Refusal to take in food and liquids produces a natural euphoria and makes the dying process easier on the client. This is an appropriate teaching statement.

The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the home health nurse's best response? 1. "I will start an IV if your husband continues to refuse to eat or drink." 2. "You should discuss placing a PEG feeding tube in your husband with the HCP." 3. "This is normal at the end of life; the dehydration produces a type of euphoria." 4. "You are right to be concerned. Would you like to talk about your worry?"

1 The nurse should address the client's comment and not "pass the buck" to someone else.

The wife of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse? 1. "I will call the chaplain to come and talk to you." 2. "Do you have any family support to be with you?" 3. "You don't know how you will make it if something happens." 4. "Do not worry, everything will be all right. You are a strong woman."

1 Because laboratory values called into a unit usually include critical values, the charge nurse should tell the unit secretary "to show me any lab information that is called in immediately." The charge nurse must evaluate this information immediately.

Thechargenurseonavascularunitisworkingwithanewunitsecretary.Whichstatement concerning laboratory data is most important for the charge nurse to tell the unit secretary? 1. "Be sure to show me any lab information that is called in to the unit." 2. "Make sure to file the reports on the correct client's chart." 3. "Do not take any laboratory reports over the telephone." 4. "Verify all telephone reports by calling back to the lab."

4 Speech therapists address swallowing problems, and clients with MG are dysphagic and are at risk for aspiration; the speech therapist can help match food consistency to the client's ability to swallow and thus help enhance client safety. This referral would be appropriate in the critical care unit.

To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis (MG)? 1. Occupational therapist. 2. Physical therapist. 3. Social worker. 4. Speech therapist.

1 The trough should be drawn before the aminoglycoside, vancomycin, antibiotic is hung. This requires intervention by the critical care charge nurse.

Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse? 1. The LPN has the trough drawn after hanging the aminoglycoside. 2. The LPN changes out a "sharps" container that is over the fill line. 3. The LPN asks another nurse to observe wastage of a narcotic. 4. The LPN inserts an indwelling urinary catheter into the client.

2 This is a violation of HIPAA. The client's right to confidentiality is being compromised because anyone could read the client's record on the computer. The charge nurse should intervene.

Which action by the primary nurse requires immediate intervention by the charge nurse? 1. The nurse is teaching the client how to use a glucometer. 2. The nurse leaves the computer screen open at the nurse's station. 3. The nurse is discussing a client situation on the phone with the HCP. 4. The nurse contacts the chaplain to come and talk to a client.

1 Tying a client to a chair is a form of restraint, and the client cannot be restrained without an HCP order; therefore, the nurse should immediately free the client. This is a legal issue.

Which action by the unlicensed assistive personnel (UAP) warrants immediate intervention by the nurse? 1. The UAP tied the confused client to a chair with a sheet. 2. The UAP escorted the client downstairs to smoke a cigarette. 3. The UAP bought the client a carbonated beverage from the cafeteria. 4. The UAP assisted the client to ambulate to the dayroom area.

3 This is a form of restraint, and the UAP cannot restrain the client in the home or in the acute care setting. This behavior warrants intervention by the nurse.

Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse caring for the client with type 2 diabetes with chronic renal disease who is on hemodialysis? 1. The UAP times the client's activities to help conserve energy. 2. The UAP applies a lubricant to the lips and oral mucous membranes. 3. The UAP ties a sheet around the client sitting in the chair. 4. The UAP uses a fan to facilitate movement of cool air.

1, 3, 4, and 5 are correct. This is an example of an activity the home health nurse would implement in the home. This is an example of an activity the home health nurse would implement in the home. This is an example of an activity the home health nurse would implement in the home. This is an example of an activity the home health nurse would implement in the home.

Which activities are examples of home healthcare nurse responsibilities when caring for clients with endocrine disorders? Select all that apply. 1. Complete nutritional counseling and teaching for a client on a high-fiber diet. 2. Discuss preoperative teaching for the client having a total right hip replacement. 3. Manage oxygen therapy for a client with chronic obstructive pulmonary disease (COPD). 4. Teach the client and family about administration and side effects of medications. 5. Draw blood for studies related to monitoring disease processes and therapy.

3 The UAP should not take money from the client to pick up prescriptions and the UAP is not responsible for doing errands for the client. If money is missing or medications are missing, this could result in a difficult situation. The home health (HH) nurse should tell the UAP not to do this type of activity for the client.

Which behavior by the UAP warrants intervention by the home health (HH) nurse? The client tells the HH nurse the UAP: 1. Would not accept a birthday gift from the client. 2. Gave the client a vase of flowers from the UAP's garden. 3. Picked up the client's prescriptions from the pharmacy. 4. Cleaned the client's bathroom, including scrubbing the commode.

3 A client with a continuous feeding tube should be in the Fowler's or high-Fowler's position to prevent aspiration pneumonia. This action requires immediate intervention by the nurse.

Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? 1. The UAP is refusing to feed the client diagnosed with acute diverticulitis. 2. The UAP would not place the client on the bedside commode who was on bed rest. 3. The UAP placed the client with a continuous feeding tube in the supine position. 4. The UAP placed sequential compression devices on the client who is on strict bed rest.

1 The client with a gastrostomy tube cannot eat or drink oral fluids; therefore, this behavior warrants intervention by the nurse.

Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the long-term care nurse? 1. The UAP is giving the client with a gastrostomy tube a glass of water. 2. The UAP is ambulating the client outside using a safety belt. 3. The UAP is assisting the client with putting a jigsaw puzzle together. 4. The UAP is giving a back rub to the client who is on bed rest.

The unlicensed assistive personnel (UAP) is violating HIPAA rules concerning confidentiality, so the clinical manager should intervene.

Which behavior warrants intervention by the clinical manager in the medical-surgical outpatient clinic? 1. The UAP is discussing a client's condition in the waiting room. 2. The LPN is talking to a client over the phone about laboratory tests. 3. The RN is triaging phone messages during his or her lunch break. 4. The UAP is taking vital signs for the client being placed in a room.

2 A parish nurse (PN) is a registered nurse with a minimum of 2 years of experience who works in a faith community, address- ing health issues of its members as well as those in the broader community or neighborhood. The client is a Presbyterian so that is the reason the parish nurse should care for this client.

Which client is most appropriate for the parish nurse to care for? 1. The post-gestational diabetic client who had triplets and is a single parent. 2. The Presbyterian client who is confined to the home due to severe arthritis. 3. The obese client with Cushing's syndrome who is requesting help with losing weight. 4. The client with chronic renal disease who is being cared for in the home by the wife.

2 It would be appropriate to assign this client to a case manager since this client has two chronic illnesses, often having multiple hospitalizations and chronic complications and requires long-term healthcare.

Which client is priority to be assigned to a case manager in the outpatient clinic so that care can be achieved? 1. The client with renal calculi who is 2 weeks post-lithotripsy procedure. 2. The client who has type 2 diabetes and coronary artery disease (CAD). 3. The client who is diagnosed with hypothyroidism receiving radiation treatment. 4. The client with Addison's disease who is on corticosteroid therapy.

2 The client with ARDS is expected to have difficulty breathing but of these four clients, the client with breathing difficulty has priority. Apply Maslow's Hierarchy of Needs. ARDS is the sudden failure of the respiratory system. A person with ARDS has rapid breathing, difficulty getting enough air into the lungs and low blood oxygen levels.

Which client requires the immediate attention of the intensive care unit nurse? 1. The client with histoplasmosis who is having excessive diaphoresis and neck stiffness. 2. The client with acute respiratory distress syndrome (ARDS) who has difficulty breathing. 3. The client with pulmonary sarcoidosis who has a dry cough and mild chest pain. 4. The client with asbestosis who has a productive cough and chest tightness.

1 The pregnant nurse can administer antineoplastic medications to clients. The nurse should not be exposed to antineoplastic agents outside of the administration bags and tubing. The pregnant nurse can care for a client who is immunosuppressed.

Which client should the charge nurse on a medical unit assign to a nurse who is 3 months pregnant? 1. The client who is receiving chemotherapy who is immunosuppressed. 2. The client with postoperative hyperparathyroidism who has shingles (herpes zoster). 3. The client with hyperthyroidism who is receiving radioactive iodine I-131. 4. The client diagnosed with AIDS who has a cytomegalovirus infection.

1 The H&H is low, which requires the nurse to assess this client first. The nurse must take the client's vital signs, check the surgical dressing, and determine whether the client is symptomatic for hypovolemia.

Which client should the charge nurse on the rehabilitation unit assess first after receiving the a.m. shift report? 1. The client diagnosed with an open reduction and external fixation (ORIF) of the right hip who has a hemoglobin and hematocrit (H&H) of 8/24. 2. The client diagnosed with rheumatoid arthritis who has a positive rheumatoid factor (RF). 3. The client diagnosed with a Stage IV pressure ulcer who has a white blood cell (WBC) count of 14,000. 4. The client diagnosed with systemic allergies on prednisone dose pack who has a glucose level of 189 mg/dL.

1 Bronchiolitis is an inflammation of the bronchioles, which are the small airways in the lungs. Signs/symptoms include wheezy cough, rapid breathing, cyanosis, nasal flaring, muscle retractions, and fever. Because the client is exhibiting expected signs/symptoms this client should be assigned to the graduate nurse.

Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation? 1. The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing. 2. The client diagnosed with pneumonia who has dull percussion and vocal fremitus. 3. Theclientdiagnosedwithaflailchestwhohasparadoxicalmovementofthechestwall. 4. The client diagnosed with reactive airway disease who has bilateral wheezing.

1 This client should be seen first because clear nasal drainage could be cerebrospinal fluid (CSF), which is a potentially life-threatening complication from surgery. The nurse needs to determine if the drainage has glucose. If it does, it is CSF and the surgeon needs to be notified.

Which client should the endocrinology nurse assess first after receiving the shift report? 1. The client who is 1 day postoperative transsphenoidal hypophysectomy who has clear drainage from the nose. 2. The client diagnosed with Grave's disease who has exophthalmos and bruits over the thyroid gland. 3. The client with hyperparathyroidism who is complaining of weakness, loss of appetite, and constipation. 4. The client with Addison's disease who has orthostatic hypotension, nausea, and vomiting.

4 The client has a urinary output of less than 30 mL/hr; therefore, this client may be going into renal failure and should be assessed first.

Which client should the nurse assess first after receiving the p.m. shift assessment? 1. The client with Barrett's esophagus who has dysphagia and pyrosis. 2. The client with proctitis who has tenesmus and passage of mucus through the rectum. 3. The client with liver failure who is jaundiced and has ascites. 4. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.

1 These ABGs show respiratory acidosis, which needs immediate intervention; therefore, this client should be assessed first.

Which client should the nurse on the vascular unit assess first after receiving shift report? 1. The client with lymphedema whose ABG results are pH 7.33, PaO2 89, PaCO2 47, HCO3 25. 2. The client with raynauds phenomenom who has bluish cold upper extremities 3. The client with chronic renal insufficiency who has an ulcerated area on the right foot. 4. The client receiving IV heparin infusion who has a PTT of 78

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

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with dyspepsia who has eructation and bloating. 2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia. 3. The client with diverticulitis who has left lower quadrant pain and fever. 4. The client with Crohn's disease who has right lower abdominal pain and diarrhea.

1 Acupressure applies pressure along the body's energy meridian. Applying pressure on the medial forearm helps decrease the client's feeling of nausea.

Which client would most benefit from acupressure, a traditional Chinese medicine, which is considered complementary alternative medicine (CAM)? 1. The client with thyroid cancer who has chemotherapy induced nausea. 2. The client with type 2 diabetes diagnosed with chronic renal disease. 3. The postpartum client who is diagnosed with Sheehan syndrome. 4. The client diagnosed with arterial hypertension.

4 The agency should be informed of the schedule so the nurse can be located if the nurse does not return when expected.

Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing? 1. If the client or family is hostile or obnoxious, call the police. 2. Carry the HH care agency identification in a purse or wallet. 3. Visits can be scheduled at night with permission from the agency. 4. Inform the agency of the times of the client's scheduled visits.

1 The nurse should assess first to determine the etiology of the incontinence before the treatment plan can be formulated. By palpating the bladder after voiding, the nurse can determine if the incontinence was the result of overdistention of the bladder.

Which intervention should the nurse implement first for the client diagnosed with urinary incontinence? 1. Palpate the bladder after an incontinent episode. 2. Administer oxybutynin, an anticholinergic agent. 3. Ensure the client does not sit or lie in the urine. 4. Instruct the client to go to the bathroom every 2 hours.

3 Oxygen must be administered to treat hypoxia, which occurs after a fat embolism; therefore, this is the nurse's first intervention.

Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism? 1. Assess the client's bilateral breath sounds. 2. Encourage the client to cough and deep breathe. 3. Administer oxygen via nasal cannula. 4. Prepare to administer intravenous heparin therapy.

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

Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP) when caring for the client who is 2 days postoperative open surgery of the kidney? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's flank surgical dressing for drainage. 3. Take and record the client's vital signs and pulse oximeter reading. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

1, 2, and 5 are correct. This is an intervention the nurse should establish with every client. Exercises with large muscles allow the release of nervous tension and restlessness. Tremors can interfere with small-muscle coordination. A calm, quiet, cool room should be provided because increased metabolism causes sleep disturbances and the feeling of being hot.

Which interventions should the nurse implement for the client diagnosed with hyperthyroidism? Select all that apply. 1. Establish a supportive and trusting relationship to help the client cope. 2. Assist with exercises involving large muscle groups. 3. Instruct the unlicensed assistive personnel (UAP) to apply multiple blankets to the bed 4. Explain that the caregiver should not leave the client alone. 5. Place the client in a cool room away from high-traffic areas.

4 This is a potential life-threatening nursing diagnosis and is the client's priority. This is the reason for the three-way continuous bladder irrigation.

Which nursing diagnosis is priority for the client who has undergone a transurethral resection of the prostate (TURP)? 1. Potential for sexual dysfunction. 2. Potential for altered urinary elimination. 3. Potential for infection. 4. Potential for hemorrhage.

4 The client will be on a regular insulin drip, which must be maintained at the prescribed rate on an intravenous pump device. Decreasing the client's blood glucose level is the priority nursing intervention.

Which nursing intervention is priority for the intensive care nurse to implement when caring for a client diagnosed with diabetic ketoacidosis (DKA)? 1. Assess for a fruity breath odor. 2. Check blood glucose levels ac and hs. 3. Monitor the client's pulse oximeter readings. 4. Maintain the regular insulin IV rate on an infusion pump.

1 Fluid and electrolyte imbalance is priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.

Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid and electrolyte imbalance. 2. Alteration in bowel elimination. 3. Nutrition, altered: less than body requirements. 4. Oral mucous membrane, altered.

1 The LPN is qualified to perform a sterile procedure, such as inserting an indwelling catheter before surgery. This is an appropriate assignment.

Which nursing task should the nurse on the renal unit assign to the licensed practical nurse (LPN)? 1. Insert an indwelling urinary catheter before surgery. 2. Turn and reposition the client every 2 hours. 3. Measure and record the urine in the bedside commode. 4. Feed the client who choked on food during the last meal.

2, 3, 4, 5 The nurse should be able to organize his or her own workload before becoming a role model for a new nurse. If the nurse is not organized, taking on new responsibilities will be very frustrating for the preceptor and for the preceptee. The nurse who acts as a preceptor should have good people skills and be approachable. The nurse should consistently provide quality care that others should emulate. The nurse should be willing to take on this responsibility or the preceptor will resent the new nurse.

Which of the staff nurse's personal attributes is an important consideration for the unit manager when discussing making an experienced nurse a preceptor for new graduates? Select all that apply. 1. The nurse's need for the monetary stipend. 2. The nurse's ability to organize the work. 3. The ability of the nurse to interact with others. 4. The quality of care the nurse provides. 5. The nurse's willingness to be a preceptor

4 Guillain-Barré syndrome produces ascending paralysis that will cause respiratory failure; therefore, breathing pattern is priority.

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome who is admitted to the critical care unit? 1. Decreased cardiac output. 2. Fear and anxiety. 3. Complications of immobility. 4. Ineffective breathing pattern.

2 The priority intervention to prevent skin impairment is frequent position changes along with skin care and nutritional support.

Which priority intervention should the nurse implement to help prevent pressure ulcers in the client who is on strict bed rest? 1. Provide adequate skin care for the client. 2. Turn the client every 2 hours or more often. 3. Ensure sufficient nutritional intake. 4. Use pressure-relieving devices such as waterbeds.

3 To maintain flexibility, the client should exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. This statement indicates the client needs more teaching.

Which statement by the client experiencing exophthalmos indicates the client needs more teaching by the endocrinology nurse? 1. "I will use artificial tears to moisten my eyes." 2. "I need to wear dark glasses to prevent irritation." 3. "I should not move my eyes unless absolutely necessary." 4. "I should lightly tape my eyes shut when I sleep"

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

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

1 The LPN can change sterile dressings according to his or her scope of practice.

Which task is most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? 1. Tell the LPN to change the client's subclavian dressing. 2. Request the LPN to obtain the client's daily weight. 3. Assign the LPN to care for the client in myxedema coma. 4. Ask the LPN to complete discharge teaching to the client.

2 The client is stable because he or she is being sent home; therefore, the UAP could safely complete this task.

Which task is most appropriate for the clinic nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to ride in the ambulance with a client. 2. Ask the UAP to escort the client in a wheelchair to the car. 3. Instruct the UAP to show the client how to use crutches. 4. Tell the UAP to call the pharmacy to refill a prescription.

4 The UAP can wash and dry the client's hair, as this is the least invasive task, so this would be the most appropriate task for the nurse to delegate to the UAP.

Which task is most appropriate for the home healthcare nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to give the herb ginkgo biloba to the client with Alzheimer's. 2. Ask the UAP to perform the tube feedings for a client with a gastrostomy tube. 3. Request the UAP to perform the daily colostomy irrigation for the client. 4. Tell the UAP to wash and dry the client's hair.

1 The UAP can take food to the client since this is not a medication and the client is stable.

Which task is most appropriate for the medical nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to take the diabetic client's HS snack to the client. 2. Ask the UAP to escort the client on the PCA pump to the bathroom. 3. Tell the UAP to witness the client's advance directive. 4. Ask the UAP to show the client how to take the client's radial pulse.

1 The unlicensed assistive personnel (UAP) can escort a client who is stable to the radiology department; therefore, this is the most appropriate task to delegate to the UAP.

Which task is most appropriate for the nurse on the renal unit to delegate to the unlicensed assistive personnel (UAP)? 1. Escort the client with acute polynephritis to the radiology department for a CT scan. 2. Obtain a sterile urine specimen for the client to rule out (R/O) a urinary tract infection. 3. Hang the bag of D5W for the client diagnosed with post-streptococcal glomerulonephritis. 4. Provide discharge instructions for the client diagnosed for nephrotic syndrome.

2 The nurse could request that another nurse administer pain medication so that the client obtains immediate pain relief.

Which task is most appropriate for the nurse to delegate/assign when caring for clients on a surgical unit? 1. Instruct the licensed practical nurse (LPN) to feed the client who is 1 day post- operative unilateral thyroidectomy. 2. Ask another nurse to administer an IVP pain medication to a postoperative client in severe pain. 3. Request the unlicensed assistive personnel (UAP) to check the client whose vital signs are AP 112, RR 26, BP 92/58. 4. Instruct the licensed practical nurse (LPN) to obtain the pre-transfusion assessment on a postoperative client.

3 The UAP can apply ice to the right ankle since the client is stable

Which task should the employee health nurse delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP read the PPD result administered to the client 72 hours ago. 2. Ask the UAP to obtain a urine specimen for the client having a urine drug screening. 3. Tell the UAP to apply an ice pack to the client who slipped and has a sprained right ankle. 4. Instruct the UAP to complete the incident report for the nurse who had a "dirty needle stick."

1 Getting a resident up in a wheelchair for meals is an appropriate delegation to an unlicensed assistive personnel (UAP). This task does not require nursing judgment.

Which task should the nurse in the long-term care facility delegate to the unlicensed assistive personnel (UAP)? 1. Assist the resident up in a wheelchair for meals. 2. Assess the incontinent client's perianal area. 3. Discuss requirements with the client for going out on a pass. 4. Explain how to care for the client's colostomy to the family.

4 The UAP is a vital part of the healthcare team and should be encouraged to attend the multidisciplinary team meeting and provide input into the client's care.

Which task should the rehabilitation nurse delegate to the unlicensed assistive personnel (UAP)? 1. Tell the UAP to show the client how to perform self-catheterization. 2. Ask the UAP to place the newly confused client in the inclusion bed. 3. Request the UAP give the client 30 mL of Maalox, an antacid. 4. Encourage the UAP to attend the multidisciplinary team meeting.

1 and 4 are correct. 1. The UAP can perform mouth care on a client who is stable. 4. The UAP can take the empty blood bag to the laboratory.

Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Perform mouth care on the client with pneumonia. 2. Apply oxygen via nasal cannula to the client. 3. Empty the trashcans in the clients' rooms. 4. Take the empty blood bag back to the laboratory. 5. Show the client how to ambulate on the walker.

1 The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition.

he critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.

3 This statement indicates the client needs more teaching because knee-high stockings will further decrease circulation to the legs.

The nurse is teaching the client diagnosed with arterial occlusive disease. Which statement indicates the client needs more teaching? 1. "I will wash my legs and feet daily in warm water." 2. "I should buy my shoes in the afternoon." 3. "I must wear knee-high stockings." 4. "I should not elevate my legs."

3 The LPN can administer medications to a client.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate to assign/delegate? 1. Instruct the UAP to discontinue the client's total parenteral nutrition. 2. Ask the UAP to give the client 30 mL of Maalox for heartburn. 3. Tell the LPN to administer a bulk laxative to a client diagnosed with constipation. 4. Request the LPN to assess the abdomen of a client who has had complaints of pain.

4 The UAP can obtain a glucometer reading on a client who is stable, and clients in the ambulatory care unit are stable.

Which task should the ambulatory care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Ask the UAP to remove the trash from the room of the client who received radioactive iodine with hyperthyroidism. 2. Instruct the UAP to escort the client outside who is asking to smoke a cigar. 3. Request the UAP check the surgical dressing on the client with an ileal conduit. 4. Tell the UAP to take the glucometer reading on the client about to go to surgery.

1 The ventilator should be checked to determine which alarm is sounding. This is the first step in assessing the client's problem.

While the nurse is caring for a client on a ventilator the ventilator alarm sounds. What is the first action taken by the nurse? 1. Silence the ventilator alarm. 2. Notify the respiratory therapist. 3. Assess the client's respiratory status. 4. Ventilate the client using a manual resuscitation bag.

1 The nurse needs to intervene because the client is at high risk for developing pneumonia, especially due to the abdominal incision.

A client is 2 days postoperative abdominal aortic aneurysm repair. Which data require immediate intervention from the nurse? 1. The client refuses to take deep breaths and cough. 2. The client's urinary output is 300 mL in 8 hours. 3. The client has hypoactive bowel sounds. 4. The client's vital signs are T 98, P 68, R 16, and BP 110/70.

2 The most important action the wife can take if her husband has a seizure is to make sure he does not get injured during the seizure. Moving all the furniture out of the way will help ensure the client's safety.

A client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. Which statement indicates the wife understands the most important action to take if her husband has a seizure? 1. "I should check to see if my husband urinates on himself." 2. "I will move all the furniture out of his way." 3. "I will call 911 as soon as the seizure begins." 4. "I will make sure he rests after the seizure is over."

4 This is an example of autonomy.

A 90-year-old male client was recently widowed after more than 60 years of marriage. The client was admitted to a long-term care facility and is refusing to eat. Which intervention is an example of the ethical principle of autonomy? 1. Place a nasogastric feeding tube and feed the client. 2. Discuss why the client does not want to eat anymore. 3. Arrange for the family to bring food for the client. 4. Allow the client to refuse to eat if he wants to.

1 The client is exhibiting signs of hypoglycemia; therefore, the nurse should treat the client's symptoms with a simple carbohydrate, such as glucose tablets. This is the first intervention.

At 1000, the client diagnosed with type 1 diabetes is complaining of being jittery, having a headache, and being dizzy. Which intervention should the nurse implement first? 1. Give the client glucose tablets. 2. Provide the client with the lunch meal. 3. Request the laboratory to draw a serum glucose level. 4. Determine the last time the client received insulin.

1 The problem is not a nursing problem. The HCP should be discussing the problem with an individual from the department that "owns" the problem.

At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client's chart. Which is the most appropriate response by the charge nurse? 1. Call the lab and have the lab supervisor talk with the HCP. 2. Discuss the HCP's complaints with the nursing supervisor. 3. Form a committee of lab and nursing personnel to fix the problem. 4. Tell the HCP to stop yelling and calm down.

2 The nurse should first ask the staff member not to discuss the client with a friend. Discussing any information about a client is a violation of HIPAA.

In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse? 1. Do not approach the staff member in the restaurant. 2. Ask the staff member not to discuss anything about the client. 3. Contact the staff member's clinical manager and report the behavior. 4. Tell the client that the staff member was discussing confidential information.

3 The nurse should remove the mother from the room and allow her to ventilate her feelings about the accident her son sustained while he was under the influence.

The 18-year-old client diagnosed with renal trauma is admitted to the critical care unit after a serious motor vehicle accident resulting from driving under the influence. The mother comes to the unit and starts yelling at her son about "driving drunk." Which action should the nurse implement? 1. Allow the mother to continue talking to her son. 2. Notify the hospital security to remove the mother. 3. Escort the mother to a private area and talk to her. 4. Tell the mother if she wants to stay, she must be quiet.

2 Assessing the client's intake will help the nurse to determine the extent of the client's complaints. This is the first intervention.

The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first? 1. Have the family bring food from home for the client. 2. Check to see what the client has eaten in the past 24 hours. 3. Tell the client that a low-sodium diet is an important part of the diagnosis. 4. Ask the dietician to discuss food preferences with the client.

1 The client is allergic to iodine; therefore, the client cannot have the CT scan with contrast because it is iodine. The nurse should question this HCP order.

The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? 1. Schedule for CT scan with contrast in a.m. 2. Administer acetaminophen 2 PO for headache. 3. Take client's vital signs per protocol. 4. Provide the client with a low-fat, low-cholesterol diet.

4 The nurse is acting appropriately, and there is no reason to discuss the instructions further. The charge nurse should continue with other duties.

The charge nurse on a vascular postsurgical unit observes a new graduate telling an elderly client's spouse not to push the client's patient-controlled analgesia (PCA) pump button. Which action should the charge nurse implement? 1. Encourage the visitor to push the button for the client. 2. Ask the nurse to step into the hallway to discuss the situation. 3. Discuss the hospital protocol for the use of PCA pumps. 4. Continue to perform the charge nurse's other duties.

3 The client must be confined to the home or require a considerable and taxing amount of effort to leave the home for brief periods to be eligible for home healthcare.

The client diagnosed with type 2 diabetes who has chronic renal disease asks the nurse, "How can I qualify for home healthcare when I go home?" Which statement is the nurse's best response? 1. "You must need constant skilled care by the nurse." 2. "You must have a family member living with you." 3. "You must be homebound to receive home healthcare." 4. "You must be referred by the hospital social worker."

2 Moist heat, immobilization, elevation, and systemic antibiotics are the cellulitis, which is an inflammation of subcutaneous tissue.

The client has cellulitis on the right lower leg. Which intervention should the nurse implement? 1. Place the client's right arm in the dependent position. 2. Apply warm moist heat to the affected area. 3. Wash the affected area with antistaphylococcal soap. 4. Wrap the right arm with ACE bandages.

3 One of the guidelines for admission to a hospice agency is a terminal process with a life expectancy of 6 months or less. These organizations work to assist the client and family to live life to its fullest while providing for comfort measures and a peaceful, dignified death.

The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time? 1. A home health nurse. 2. The client's pastor. 3. A hospice agency. 4. The social worker.

3 The client's apical pulse (AP) is above normal and the B/P is low, which are signs of hypovolemic shock, which warrants immediate intervention by the nurse.

The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? 1. The client's hemoglobin/hematocrit is 11.4/32. 2. The client's abdomen is soft to touch and non-tender. 3. The client's vital signs are T 99, AP 114, RR 18, B/P 88/60. 4. The client's nasogastric tube has coffee ground drainage.

3 The client is at high risk for cardiac dysrhythmias, due to hypokalemia. The nurse should first assess the cardiac status, then implement other interventions. Remember Maslow's Hierarchy of Needs.

The client is experiencing severe diarrhea and a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Assess the client for leg cramps. 3. Place the client on cardiac telemetry. 4. Prepare to administer intravenous potassium.

1 The nurse should first discontinue the medication that is causing the increase in the client's blood pressure prior to doing anything else.

The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client's vasoconstrictor, dopamine. 2. Notify the client's healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client's neurological status.

2 The first intervention for the supervisor is to ensure that all the jobs in the code are being filled.

The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurse's first intervention during the code? 1. Begin to take notes to document the code. 2. Make sure all the jobs are being done. 3. Arrange for an intensive care unit bed. 4. Administer the emergency medications.

2 Extension of the upper and lower extremities is assuming a decerebrate posture, which indicates the client's intracranial pressure (ICP) is increasing. This would warrant immediate intervention by the nurse.

The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. 4. The client is able to squeeze the nurse's hand on a verbal request.

1 The nurse should first care for the client and refer the client to an HCP for possible x-rays, pain medication, and further treatment. The employee health nurse's responsibility is to ensure the employee is safe to work, and this client is not.

The employee health nurse is caring for an employee who fell off a ladder and is complaining of low back pain radiating down both legs. Which intervention should the nurse implement first? 1. Refer the client to an HCP for further evaluation. 2. Complete the workers' compensation documentation. 3. Investigate the cause of the fall off the ladder. 4. Notify the employee's supervisor of the incident

2 The first action is to ask the person directly to stop. The harasser needs to be told in clear terms that the behavior makes the nurse uncomfortable and that he wants it to stop immediately.

The female charge nurse on the respiratory unit tells the male nurse, "You are really cute and have a great body. Do you work out?" Which action should be taken by the male nurse if he thinks he is being sexually harassed? 1. Document the comment in writing and tell another staff nurse. 2. Ask the charge nurse to stop making comments like this. 3. Notify the clinical manager of the sexual harassment. 4. Report this to the corporate headquarters office.

3 The nurse must have knowledge of disease processes. The client is verbalizing signs of acute diverticulitis, which requires the client to be NPO and prescribed antibiotics. The client needs to receive immediate medical attention.

The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, "I am having really bad pain in my left lower stomach and I think I have a fever." Which action should the nurse take? 1. Recommend the client take an antacid and lie flat in the bed. 2. Instruct one of the nurses to visit the client immediately. 3. Tell the client to have someone drive them to the emergency room. 4. Ask the client what she has had to eat in the last 8 hours.

3 The client must be taught the long-term effects of hyperglycemia. A hemoglobin A1C of 11 indicates an average blood glucose of 310 mg/dL. Over time, a level higher than 120 to 140 mg/dL can lead to damage to many body systems.

The client diagnosed with diabetes mellitus type 2 has a hemoglobin A1C of 11 mg/dL. Which intervention should the nurse implement first? 1. Check the client's current blood glucose level. 2. Assess the client for neuropathy and retinopathy. 3. Teach the client about the effects of uncontrolled hyperglycemia. 4. Monitor the client's BUN and creatinine levels.

3 Mittens will help prevent the client from scratching the skin and causing skin breakdown, which is priority for the client with liver failure. The client has decreased Vitamin K, which will lead to bleeding. The client is also immunosuppressed, which will lead to infection.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice and is scratching the upper extremities. Which intervention should the nurse implement first? 1. Request the UAP to assist the client to take a hot, soapy shower. 2. Apply an emollient to the client's upper extremities. 3. Place mittens on both hands of the client. 4. Administer Benadryl 25mg PO to the client.

3 The UAP can strain the client's urine. This task does not require judgment or evaluation. Any sediment should be placed in a sterile container and sent to the laboratory for analysis.

The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Tell the UAP to check the amount, color, and consistency of the client's urine output. 2. Request the UAP to transcribe the client's healthcare provider's orders. 3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container. 4. Ask the UAP to take the client's post-procedural vital signs.

1 Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings. The client is still grieving over her loss, and the nurse should let her vent feelings.

The home health (HH) nurse is caring for a 22-year-old female client who sustained an L-5 spinal cord injury 2 months ago. The client says, "I will never be happy again. I can't walk, I can't drive, and I had to quit college." Which intervention should the nurse implement first? 1. Allow the client to ventilate her feelings of powerlessness. 2. Refer the client to the home healthcare agency social worker. 3. Recommend contacting the American Spinal Cord Association. 4. Ask the client whether she has any friends who come and visit.

2 The family and friends will have returned to their own lives 1 to 2 months after a family member has died. This is when the next of kin needs support from the hospice nurse. Hospice will follow up with the significant other for up to 13 months.

The hospice nurse is providing follow-up care with the family member of a client who died with chronic renal disease. Which intervention is priority? 1. Attend the client's funeral service or visitation. 2. Check on the family 1 to 2 months after the death of the client. 3. Make sure the arrangements are what the client wanted. 4. Help the family member dispose of the client's belongings as soon as possible.

3 One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately.

The hospice nurse is triaging phone calls from clients. Which client should the nurse call first? 1. The client whose family reports the client is not eating. 2. The client who wants to rescind the out-of-hospital DNR. 3. The client whose pain is not being controlled with the current medications. 4. The client whose urinary incontinence has caused a Stage 1 pressure ulcer.

3 The client has peripheral neuropathy, which produces shooting pain in the extremities. The priority at the end of life is to keep the client comfortable.

The hospice nurse is writing a care plan for a client diagnosed with type 2 diabetes mellitus who has peripheral neuropathy. Which client problem has priority for the client? 1. Altered glucose metabolism. 2. Anticipatory grieving. 3. Alteration in comfort. 4. Spiritual distress.

2 The nurse should notify the charge nurse first so the hospital protocol can be followed, including notifying the infection control nurse, completing an incident report, obtaining blood from the client, and starting prophylactic medication if warranted.

The nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. The nurse flushes the skin with water and tries to get the area to bleed. Which action should the nurse implement next? 1. Have the laboratory draw the client's blood. 2. Notify the charge nurse and complete the incident report. 3. Contact the employee health nurse to start prophylactic medication. 4. Follow up with the employee health nurse to have lab work drawn.

1 This statement indicates the new graduate needs more teaching because the nurse is responsible for delegating the right task to the right individual. Absolutely no one works on the nurse's license but the nurse holding the license.

The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching? 1. "The UAP will be practicing on my brand-new nursing license." 2. "I will still retain accountability for what I delegate to the UAP." 3. "I must make sure the UAP to whom I delegate is competent to perform the task." 4. "When I delegate, I must follow up with the UAP and evaluate the task."

2 Safety is the highest priority for clients diagnosed with end-stage Alzheimer's disease because the client is unaware of his or her own surroundings and can easily wander from an area of safety.

The nurse in a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer's disease. Which client problem is priority for this client? 1. Inability to do activities of daily living. 2. Increased risk for injury. 3. Potential for constipation. 4. Ineffective family coping.

3 Massage and moist hot packs to the neck and head can help a client with tension-type headaches. This statement indicates the client needs more teaching.

The nurse is teaching the client with tension-type headaches. Which statement indicates the client needs more teaching? 1. "I will do some type of exercise every day." 2. "I am going to do yoga techniques when I get a headache." 3. "Cold packs to the back of my neck will help my headache." 4. "Foods containing amines like cheese and chocolate can cause headaches."

3 Cystic fibrosis is a genetic condition that results in blockage of the pancreatic ducts. The child needs pancreatic enzymes to be administered with every meal and snack so the enzymes will be available when the food gets to the small intestine.

The nurse is teaching the parents of a child diagnosed with cystic fibrosis. Which information is priority to teach the parents? 1. Explain that the child's skin tastes salty. 2. Observe the consistency of the stools daily. 3. Give pancreatic enzymes with every meal. 4. Increase the intake of salt in the child's diet.

1 The nurse must first obtain the operative permit, or determine whether it has been signed by the client, prior to implementing any other orders.

The nurse is transcribing the HCP's orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? 1. Obtain the client's informed consent. 2. Administer 2 mg of IV morphine, every 4 hours, PRN. 3. Shave the lower right abdominal quadrant. 4. Administer the on-call IVPB antibiotic.

3 This client needs to be contacted so culture and sensitivity (C&S) can be done and mild analgesics prescribed. The ear canal has to be cleansed and antibiotic ear drops administered to the ear. Otalgia is ear pain. This client should be contacted for treatment.

The nurse is triaging phone calls in a neurosensory clinic. Which client should the nurse contact first? 1. The client with Méniére's disease who is complaining of vertigo and tinnitus. 2. The client with otitis media with effusion complaining of feeling of fullness in the ear. 3. The client with external otitis who has serosanguineous drainage and otalgia. 4. The client with otoclersosis who has bilateral hearing loss.

2 During a disaster, the priority is to determine whether the client has routine medications that can be taken while in the shelter. If clients have life-sustaining medications, then obtaining the medications becomes priority. Remember, psychiatric medications are life sustaining.

The nurse is working at the emergency health clinic in a disaster shelter. Which intervention is priority when initially assessing the client? 1. Find out how long the client will be in the shelter. 2. Determine whether the client has his or her routine medications. 3. Document the client's health history in writing. 4. Assess the client's vital signs, height, and weight.

3 Acute bronchitis is an inflammation of the bronchial tubes, the major airways into the lungs. The client is exhibiting expected signs/symptoms; therefore, the LPN could care for this client.

The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN? 1. The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. 2. The client diagnosed with pneumonia whose pulse oximeter reading is 90%. 3. The client with acute bronchitis who has a chronic clear mucous cough and low fever. 4. The client with reactive airway disease who has bilateral wheezing.

4 The client must be medicated with a narcotic medication prior to being taken to whirlpool, which is a physiological need; therefore, the nurse should see this client first.

The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first? 1. The client with a right total knee replacement who wants to be removed from the continuous passive motion (CPM) machine. 2. The client diagnosed with chronic low back pain who is crying and upset about being discharged home. 3. The client who is 1 week postoperative for right total hip replacement (THR) who has a temperature of 100.4°F. 4. The client who has full-thickness burns who needs to be medicated before being taken to whirlpool.

2 The client who is exhibiting air hunger indicates respiratory distress; therefore, a tracheostomy tray should be obtained first.

The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority? 1. Assist the HCP with a sterile dressing change for a client with a left pneumonectomy. 2. Obtain a tracheostomy tray for a client who is exhibiting air hunger. 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED. 4. Assess the client diagnosed with mesothelioma who is upset, angry, and crying.

2 The case manager's job is to ensure continuity and adequacy of care for the client. This individual has a "need to know."

The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? 1. Discuss personal information the client shared with the nurse in confidence. 2. Provide the case manager with any information that is required for continuity of care. 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the case manager to get the client's permission before sharing information.

3 Respiratory therapists assess and treat clients with lung problems multiple times every day. Therefore, this is the best person to consult when the nurse needs help identifying a respiratory problem.

The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first? 1. The healthcare provider. 2. The unit manager. 3. The respiratory therapist. 4. The case manager.

1 The therapeutic PTT level should be 1.5 to 2 times the normal PTT of 39 seconds. The therapeutic levels of heparin are 58 and 78. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first.

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92. 2. The client on peritoneal dialysis who has a clear dialysate draining from the abdomen. 3. The client on hemodialysis whose right upper arm fistula has an audible bruit. 4. The client diagnosed with cystitis who is complaining of burning on urination.

3 The nursing home should send a transfer form with the client that details current medications and diagnoses as well as hygiene needs. Previous hospital records will include a history and physical examination and a discharge summary. This is the best place to start to glean information regarding the client.

An elderly female client is admitted from the long-term care facility with hyperglycemic hyperosmolar nonketotic coma. The client does not have any family or friends present. Which resource(s) should the admission nurse utilize to obtain information about the client? 1. The nurse should wait until a significant other can be contacted. 2. The verbal report from the ambulance workers and STAT lab work. 3. The transfer form from the nursing home and old hospital records. 4. The healthcare provider's telephone orders about care needed.

3 The clinic nurse should correct the UAP's behavior, but it should be donein private and with an explanation as to why the action is inappropriate. This isa violation of confidentiality becausethe scale is located in the office area and any client or visitor passing by, as wellas other staff members, can hear the comment.

The cardiac clinic nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the office area. Which action should the clinic nurse implement? 1. Tell the UAP in front of the client to not comment on the weight. 2. Ask the UAP to put the client in the room and take no action. 3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA. 4. Report the UAP to the director of nurses of the clinic.

4 A PT/PTT will assess the client for any bleeding tendencies. This is priority before this surgery because bleeding is a life-threatening complication.

The clinic nurse is scheduling a 14-year-old client for a tonsillectomy. Which intervention should the clinic nurse implement? 1. Obtain informed consent from the client. 2. Send a throat culture to the laboratory. 3. Discuss the need to cough and deep breathe. 4. Request the laboratory to draw a PT and a PTT.

1 The nurse should "offer self " to the significant other. Ignoring the needs of the significant other at this time makes the significant other feel that the nurse does not care, and if the nurse does not care for "me," then did the nurse provide adequate care to my loved one? This action is very important to assist in the grieving process.

The client in a critical care unit died. What action should the nurse implement first? 1. Stay with the significant other. 2. Gather the client's belongings. 3. Perform post-mortem care. 4. Ask about organ donation.

4 The nurse should contact the fire department. Many fire departments will supply and install smoke detectors for people who cannot afford them. The nurse should investigate this option first because it is the most immediate response to the safety need.

The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home. The client tells the nurse they just cannot afford them. Which action should the nurse implement first? 1. Purchase at least one smoke detector for the client's home. 2. Notify the HH care agency social worker to discuss the situation. 3. Ask the client whether a family member could buy a smoke detector. 4. Contact the local fire department to see if they can provide smoke detectors for the client.

4 E-mail communication should be concise and easy to read. If the email requires a lot of information, then the writer should use bullets to separate information.

The healthcare facility where the nurse works uses e-mail to notify the staff of in-services and mandatory requirements. Which is important information for the nurse manager to remember when using e-mail to disseminate information? 1. Give as much information as possible in each e-mail. 2. Use e-mail for all communications with the staff. 3. Use capital letters to get a point across with emphasis. 4. Make the e-mail notices quick and easy to read.

3 The client is having respiratory distress and the ventilator is sounding an alarm; therefore, the nurse should first assess the ventilator to determine the cause of the problem and correct it because the client is totally dependent on the ventilator for breathing. This is one of the few situations wherein the nurse would assess the equipment before assessing the client.

The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Check the ventilator to resolve the problem. 4. Auscultate the client's lung sounds.

4 The LPN can contact medial supply companies and request durable medical equipment (DME); therefore, this is the most appropriate task to assign the LPN.

The nurse supervisor in the home health (HH) office is assigning tasks for the day. Which task is most appropriate for the nurse supervisor to assign the licensed practical nurse (LPN)? 1. Tell the LPN to complete the admission assessment for the client with Cushing's disease. 2. Request the LPN to evaluate the client's response to the new pain medication regime. 3. Request the LPN perform the wound care for the client with a Stage 4 pressure ulcer. 4. Instruct to the LPN to visit the client with type 2 diabetes who is stable and needs a hospital bed.

3 The nurse should first put on non-sterile gloves to protect from getting any blood-borne diseases.

The occupational nurse is caring for the client who just severed two fingers from the right hand. Which intervention should the occupational nurse implement first? 1. Place the severed fingers in a sterile cloth and then in an ice chest. 2. Instruct the client to elevate the right arm over the heart. 3. Don non-sterile gloves on both hands. 4. Apply direct pressure to the right radial pulse.

2 The UAP can make sure the room is clear of the previous client's gown and equipment used with the previous client. The UAP can also make sure there are gowns, tongue blades, and additional equipment in the examination room.

The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate? 1. Request the LPN to escort the client to the examination room. 2. Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client. 3. Instruct the RN to administer the tetanus shot to the client. 4. Tell the clinic secretary to call in a new prescription for a client.

2 Whenever there is a discrepancy on the chart or with what the client says, the nurse should call an immediate time-out until the situation has been resolved.

56. The surgical nurse is admitting a client having heart surgery to the operating room. Which information would require the nurse to call a time-out? 1. The client is drowsy from the preoperative medication and drifts off to sleep. 2. The consent form states mital valve replacement and the client states aortic valve replacement. 3. The chart and client's armband states the client is allergic to the narcotic analgesic morphine. 4. The client states his or her name and birth date as it appears on the chart.

1 The LPN can contact the HCP and give pertinent information. The INR is high (therapeutic is 2 to 3), and the HCP should be informed.

The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? 1. Tell the LPN to notify the clinic healthcare provider (HCP). 2. Instruct the LPN to assess the client for abnormal bleeding. 3. Obtain a stat electrocardiogram on the client. 4. Take no action because this INR is within the normal range

Correct Answer: 5, 4, 3, 2, 1 5. The nurse must first obtain informed consent prior to administering the blood product. 4. The nurse needs to complete the pre-transfusion assessment including assessing for any signs of allergic reac- tion prior to administering the unit of blood. 3. The blood must be hung with Y-tubing and normal saline, and an 18-gauge angiocatheter is preferred. 2. The nurse must check the unit of blood from the laboratory with another nurse and with the client's blood band. 1. During the first 15 minutes, the blood transfusion must be administered slowly to determine if the client is going to have an allergic reaction.

The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtts/min the first 15 minutes. 2. Check the unit of blood and the client's blood band with another nurse. 3. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter. 4. Assess the client's vital signs and lung sounds, and assess for a rash. 5. Obtain informed consent for the unit of blood from the client.

1, 2, 4, and 5 are correct. 1. A 2-lb weight gain indicates the client is retaining fluid and should contact the HCP. This is an appropriate teaching intervention. 2. Keeping the head of the bed elevated will help the client breathe easier; therefore, this is an appropriate teach- ing intervention. 4. Sodium retains water. Telling the client to avoid eating foods high in sodium is an appropriate teaching intervention. 5. Isotonic exercise, such as walking or swimming, helps tone the muscles, and discussing this with the client is an appropriate teaching intervention.

The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply. 1. Notify the healthcare provider (HCP) if the client gains more than 2 lb in one day. 2. Keep the head of the bed elevated when sleeping. 3. Take the loop diuretic once a day before going to sleep. 4. Teach the client which foods are high in sodium and should be avoided. 5. Perform isotonic exercises at least once a day.

3 The client's digoxin level is higher than the therapeutic level for digoxin, which is 0.8 to 2 mg/dL. This client should be contacted first to assess for signs/ symptoms of digoxin toxicity.

The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse? 1. The client who has an INR of 2.8. 2. The client who has a serum potassium level of 3.8 mEq/L. 3. The client who has a serum digoxin level of 2.6 mg/dL. 4. The client who has a glycosylated hemoglobin of 6%.

1 The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening.

The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first? 1. The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights. 2. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level. 3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 4. The client 2 days' postoperative coronary artery bypass who is being transferred to the cardiac unit.

3 A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3 Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client.

The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization.

2 The nurse with critical care experience would be the best choice to float to the emergency department.

The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department? 1. The nurse who has 4 years of experience on the cardiac unit. 2. The nurse who just transferred from critical care to the cardiac unit. 3. The nurse with 1 year of experience on the cardiac unit who has been on a week's sick leave. 4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.

3 A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client.

The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with mitral valve stenosis. 2. The client diagnosed with asymptomatic sinus bradycardia. 3. The client diagnosed with fulminant pulmonary edema. 4. The client diagnosed with acute atrial fibrillation.

3 A platelet count of less than 100,000 per milliliter of blood indicates thrombocytopenia; therefore, this client warrants intervention by the charge nurse.

The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse? 1. The client whose INR is 2.3. 2. The client whose H&H is 11 g/dL and 36%. 3. The client whose platelet count is 65,000 per milliliter of blood. 4. The client whose red blood cell count is 4.8 × 10 mm6.

3 Placing nitroglycerin under the client's tongue may relieve the client's chest pain and provide oxygen to the heart muscle. This is the nurse's first intervention.

The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first? 1. Take the client's pulse, respirations, and blood pressure. 2. Call for a stat electrocardiogram and a troponin level. 3. Place sublingual nitroglycerin 1/150 g under the tongue. 4. Notify the HCP that the client has pain.

4 Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants intervention by the nurse.

The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse? 1. "I have to go to the bathroom a lot during the morning." 2. "I get up very slowly when I have been sitting for a while." 3. "I do not salt my food when I am cooking it but I add it at the table." 4. "I drink grapefruit juice every morning with my breakfast."

1 The nurse's first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client's respiratory distress.

The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first? 1. Assist the client to a sitting position. 2. Assess the client's vital signs. 3. Call 911 for the paramedics. 4. Auscultate the client's lung sounds.

2 This behavior is unethical and is making promises that the staff nurse may or may not be able to keep. Because this situation includes the HCP, an outside representative, and the staff nurse, this situation should be reported to the director of nurses for further action.

The clinic nurse overhears another staff nurse telling the pharmaceutical representative, "If you bring us lunch from the best place in town, I will make sure you get to see the HCP." Which action should the clinic nurse take? 1. Tell the pharmaceutical representative the staff nurse's statement was inappropriate. 2. Report this behavior to the clinic's director of nurses immediately. 3. Do not take any action and wait for the food to be delivered. 4. Inform the HCP of the staff nurse's and pharmaceutical representative's behaviors.

3 This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses.

The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy? 1. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early. 2. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week. 3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly. 4. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position.

1 The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client's heart stops beating.

The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement? 1. Continue to care for the client's needs as usual. 2. Place notification of the DNR inside the client's chart. 3. Refer the client to a hospice organization. 4. Limit visitors to two at a time, so as not to tire the client.

2 The nurse should document exactly what was observed. This statement is the correct documentation.

The elderly client on the cardiac unit was found on the floor by the bed. Which information should the nurse document in the client's chart? 1. Fell. No injuries noted. Incident report completed. HCP notified. 2. Found on floor. No complaints of pain. Able to move all extremities. 3. States no one answered call light, so attempted to get up without help. 4. Got out of bed without assistance and fell by the bedside.

1 Because the client has been on the daily aspirin for more than a year, the nurse should assess for bleeding by asking questions such as, "Do your gums bleed after brushing teeth?" or "Do you notice blood when you blow your nose?"

The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first? 1. Assess the client for abnormal bleeding. 2. Instruct the client to stop taking the aspirin. 3. Recommend the client take an enteric-coated aspirin. 4. Instruct the client to notify the HCP.

2 The nurse should first take the client's BP correctly and address the client's concern.

The female client tells the charge nurse the unlicensed assistive personnel (UAP) did not know how to take her blood pressure. Which action should the charge nurse implement first? 1. Discuss the client's comment with the UAP. 2. Retake the BP and inform the client of her BP reading. 3. Explain that the UAP knows how to take a BP reading. 4. Ask the UAP to demonstrate taking a BP reading.

1 If the family is not causing a disruption in the code, the family member should be allowed to stay in the room with the supervisor remaining near the family member and explaining why the interventions are being implemented will help the client to survive. The supervisor should be ready to escort the family member out of the code if the family member becomes disruptive.

The female family member of the client experiencing a cardiac arrest refuses to leave the client's room. Which intervention should the administrative supervisor implement? 1. Stay with the family member and explain what the team is doing. 2. Call hospital security to escort the family member out of the room. 3. Ask the healthcare provider (HCP) whether the family member can stay. 4. Ignore the family member unless she becomes hysterical.

4 This is the most appropriate response because sexual harassment allegations are a legal matter. The clinic nurse implemented the correct action by making sure the unlicensed assistive personnel (UAP) reported the allegation to the director of nurses.

The female unlicensed assistive personnel (UAP) tells the clinic nurse, "One of the medical interns asked me out on a date. I told him no but he keeps asking." Which statement is the nurse's best response? 1. "I will talk to the intern and tell him to stop." 2. "Did anyone hear the intern asking you out?" 3. "He asks everyone out; that is just his way." 4. "You should inform the clinic's director of nurses."

3 The nurse should stay with the client and her husband and not make any life- rescuing interventions while the client is dying. The husband should not be left alone.

The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, "My wife is not breathing." Which intervention should the nurse implement first? 1. Contact the client's healthcare provider (HCP). 2. Notify the Rapid Response Team. 3. Stay with the client and her husband. 4. Instruct the UAP to perform post-mortem care.

3 The UAP can assist with hygiene needs; this is one of the main tasks that may be delegated to UAPs.

The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP? 1. Monitor the client's arterial blood gases. 2. Re-infuse the client's blood using the cell saver. 3. Assist the client to take a sponge bath. 4. Change the client's saturated leg dressing.

1 Federal law requires that clients present- ing to an emergency department must be assessed and treated without regard to payment. The nurse should initiate steps to assess the client.

The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first? 1. Place the client on a telemetry monitor and assess the client. 2. Call an ambulance to transfer the client to a charity hospital. 3. Have the client sign a form agreeing to pay the bill. 4. Ask the client why he chose to come to this hospital.

3 The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is deter- mined, the nurse should not delegate any client care.

The nurse and the UAP enter the client's room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first? 1. Ask the UAP to check whether the client is asleep. 2. Tell the UAP to perform cardiac compressions. 3. Instruct the UAP to get the crash cart. 4. Request the UAP to put the client in a recumbent position.

2 The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable

The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client's telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor.

3 Unlicensed assistive personnel (UAP) have the ability to keep the victims calm; therefore, this is an appropriate action. This action is not critical to the safety of the victims.

The nurse at a disaster site is triaging victims when a woman states, "I am a certified nurse aide. Can I do anything to help?" Which action should the nurse implement? 1. Request the woman to please leave the area. 2. Ask the woman to check the injured clients. 3. Tell the woman to try and keep the victims calm. 4. Instruct the woman to help the paramedics.

3 The Joint Commission has implemented this requirement for all telephone orders. The nurse should document on the HCP's order "repeat order verified."

The nurse calls the HCP for an order for pain medication for a client who is 2 days postoperative aortic aneurysm repair. The HCP gives the nurse an order for "Demerol 50 mg IVP now and then every 4 hours as needed." Which action should the nurse implement first? 1. Write the order in the chart with the words "per telephone order (TO)." 2. Request another nurse to verify the HCP's order on the phone. 3. Read back the order to the HCP before hanging up the phone. 4. Transcribe the order to the medication administration record.

3 Intravenous heparin increases the client's partial thromboplastin time and causes an anticoagulant effect. The nurse should always be aware of the client's most current PTT levels when therapeutic heparin is being administered.

The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first? 1. Check the radial pulse before administering digoxin, a cardiac glycoside. 2. Monitor the amiodorone level for the client receiving amiodorone. 3. Obtain the latest PTT results on the client with a heparin drip. 4. Check the liver function panel for the client receiving a dopamine drip.

2 This potassium level is very low. Hypokalemia potentiates dysrhythmias in clients receiving digoxin. This nurse should discuss potassium replacement with the HCP before administering this medication.

The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time (PT) of 14 and an International Normalized Ratio (INR) of 1.6 mg/dL. 2. Digoxin(Lanoxin),a cardiac glycoside, to a client with a potassium level of 3.3mEq/L. 3. Atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotransferase (AST) of 18 U/L. 4. Lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL.

4 Any time the nurse suspects the client is having a reaction to blood or blood products, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client's body. This is the nurse's first intervention.

The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Assess the client's vital signs. 2. Notify the HCP. 3. Maintain a patent IV line. 4. Stop the transfusion at the hub.

1 The client with angina should be asymptomatic; when the client is complaining of chest pain, this is abnormal data. Therefore, this client should be assessed first. Remember Maslow's Hierarchy of Needs identifies physiological needs as priority and pain is priority.

The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first? 1. The client diagnosed with angina who is reporting chest pain. 2. The client diagnosed with CHF who has bilateral 4+ peripheral edema. 3. The client diagnosed with endocarditis who has a temperature of 100°F. 4. The client diagnosed with aortic valve stenosis who has syncope.

1. The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client's age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the question that should be asked because many clients may be embarrassed to bring up the subject.

The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client? 1. "Are you sexually active?" 2. "Can you still drive your car?" 3. "Do you have pain medications at home?" 4. "Do you know when to call your HCP?"

Correct Answer: 3, 2, 4, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1-mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer's recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes.

The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client's identification band. 5. Clamp the primary tubing distal to the port.

1 The nurse should administer a unit of blood over the greatest length of time possible (4 hours) to a client diagnosed with congestive heart failure to prevent fluid volume overload. The nurse should question this order.

The nurse is preparing to administer two units of PRBCs to a client diagnosed with congestive heart failure (CHF). Which HCP order should the nurse question? 1. Administer each unit over 2 hours. 2. Administer the loop diuretic furosemide (Lasix) IVP once. 3. Restrict the client's fluids to 1000 mL per 24 hours. 4. Have a complete blood count (CBC) done the following morning.

3 The client's support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client.

The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement? 1. Assess the client's spiritual needs. 2. Assess the client's financial situation. 3. Assess the client's support system. 4. Assess the client's medical diagnosis.

4 The more research articles there are that support a change proposal, the more valid is the information, which increases the possibility for change to be considered by the healthcare facility.

The nurse is reviewing the literature to identify evidence-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse's proposal for a change in the procedure? 1. The article in which the study was conducted by the manufacturer of the product used. 2. The research article that included 10 subjects participating in the study. 3. The review-of-literature article that cited ambiguous statistics about the product. 4. The review-of-literature article that cited numerous studies supporting the product

Correct Answer: 3, 1, 4, 2, 5 3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and the temperature to see if interventions should be initiated based on a progression of the septicemia. 1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift. 4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring. 2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the problem. 5. A dressing change can take some time to complete. This is a physiological situation but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change.

The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority. 1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. 2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. 3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. 4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morning.

1 This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first.

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected.

1, 2, 3, and 5 are correct. 1. Case managers help coordinate health- care between multiple sources of healthcare attempting to contain healthcare cost. 2. The case manager is a client advocate and helps with communication between the client and healthcare providers, which, it is hoped, enhances the client's quality of life. 3. The case manager coordinates out- patient care and in-patient care, and helps with referrals for the client. The case manager is involved in assess- ing, planning, facilitating, and advocating for health services for a client, which, it is hoped, provide quality care. Trying to coordinate this is often exhausting and frustrating for the client and family.

The nurse on the cardiac unit is discussing case management with a client who asks, "Why do I need a case manager for my heart disease?" Which statements are most appropriate for the nurse to respond? Select all that apply. 1. "Case management helps contain the costs of your healthcare." 2. "It will help enhance your quality of life with a chronic illness." 3. "It decreases the fragmentation of care across many healthcare settings." 4. "Case management is a form of health insurance for clients with chronic illnesses." 5. "We try to provide quality care along the healthcare continuum."

3 The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first.

The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The cardiac glycoside to the client who has an apical pulse of 58. 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. 3. The antidysrhythmic to the client in ventricular fibrillation. 4. The calcium-channel blocker who has a blood pressure of 110/68.

1 Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a client when his or her INR level is above the therapeutic 2-3; therefore, the nurse should question administering this medication.

The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering? 1. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8. 2. Propranolol (Inderal), a beta-adrenergic, to a client with arterial hypertension. 3. Nifedipine (Procardia), a calcium channel blocker, to a client with Raynaud's disease. 4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with a sodium level of 138 mEq/L.

2 The nurse cannot assign assessment. This is the inappropriate task to assign to the LPN.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? 1. Feed the client who has an IV in both forearms. 2. Assess the client diagnosed with stage IV heart failure. 3. Discharge the client who had a cardiac catheterization. 4. Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin).

2, 3, 4 2. The cost of the research is not pertinent when reading a research article and determining whether the research supports evidence-based practice. This statement indicates the charge nurse does not understand how to read a research article. 3. A research article should answer the question "what": What research method was used? This statement indicates the charge nurse understands how to read a research article. 4. A research article should answer the question "where": In what setting was the research conducted? This statement indi- cates the charge nurse understands how to read a research article.

The staff nurse on a vascular disorder unit asks the charge nurse, "What should I be looking for when I read a research article?" Which response indicates the charge nurse does not understand how to read a nursing research article? 1. "You should be able to determine why the research was done." 2. "You should look to find out how much money was used for the study." 3. "You should evaluate which research method was used for the study." 4. "You should read the method section to find out what setting was used."

4 The nurse should immediately go to the client's room to assess the client.

The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first? 1. Notify the healthcare provider immediately. 2. Have the UAP recheck the client's vital signs manually. 3. Place the client in Trendelenburg position. 4. Assess the client's cardiovascular status.

3 The nurse should immediately go to the client's room and assess the client. Sometimes the nurse may need the client's chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room.

The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP? 1. Call the healthcare provider (HCP) and report the client's chest pain. 2. Give a client some acetaminophen (Tylenol) while the nurse checks the client. 3. Get the client's medical records and bring them to the client's room. 4. Notify the client's family of the onset of chest pain.

2 The AHA recommends the client having chest pain chew an aspirin to help decrease platelet aggregation. This is the first intervention the clinic nurse should tell the wife to do. The client is in distress; therefore, the nurse should have the wife do something.

The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won't go to the hospital. Which action should the nurse implement first? 1. Instruct the wife to call 911 immediately. 2. Tell the wife to have the client chew an aspirin. 3. Ask the wife what the client had to eat recently. 4. Request the husband talk to the clinic nurse.

4 Warm toes mean the stockings are not too tight and there is good circulation. Checking that the toes are warm indicates the HH aide understands the correct procedure for applying the compression stockings.

Which action by the unlicensed assistive personnel (UAP) indicates to the nurse the UAP understands the correct procedure for applying compression stockings to the client recovering from a pulmonary embolus? 1. The UAP instructs the client to sit in the chair when applying the stockings. 2. The UAP cannot insert one finger under the proximal end of the stocking. 3. The UAP ensures the toe opening is placed on the top side of the feet. 4. The UAP checked to make sure the client's toes were warm after putting the stockings on.

4 The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first.

Which client should the telemetry nurse assess first after receiving the a.m. shift report? 1. The client diagnosed with deep vein thrombosis who has an edematous right calf. 2. The client diagnosed with mitral valve stenosis who has heart palpitations. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with congestive heart failure who has pink frothy sputum.

4 Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.

Which client warrants immediate intervention by the nurse? 1. The client diagnosed with pericarditis who has chest pain with inspiration. 2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. 3. The client diagnosed with Marfan syndrome who has pectus excavatum. 4. The client diagnosed with atherosclerosis who has slurred speech and drooling.

1 The therapeutic level for digoxin is0.8 to 2.0 so this warrants notifying the HCP.

Which laboratory data should the nurse in the long-term care unit notify the healthcare provider about? 1. The client receiving digoxin who has a digoxin level of 2.6. 2. The client receiving enoxaparin (Levonox) who has a PT of 12.9 seconds. 3. The client receiving ticlopidine (Ticlid) who has a platelet count of 160,000. 4. The client receiving furosemide (Lasix) who has a potassium level of 4.2 mEq/L.

3 Trental is a PO medication prescribed specifically to treat intermittent claudication. It increases erythrocyte flexibility and reduces blood viscosity.

Which medication is most appropriate for the nurse to assign to the LPN to administer? 1. The intravenous push antiemetic to the client who is nauseated and vomiting. 2. The subcutaneous low-molecular-weight heparin to the client with a pulmonary embolus. 3. The PO pentoxifylline (Trental) to the client who has intermittent claudication. 4. The sublingual nitroglycerin to the client who is complaining of chest pain.

1 First-dose intravenous antibiotic medications are priority medications and should be administered within 1 to 2 hours of when the order was written. This should be the first medication administered.

Which medication should the nurse administer first after receiving the morning shift report? 1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today. 2. The antiplatelet medication to the client who had a myocardial infarction. 3. The coronary vasodilator patch to the client with coronary artery disease. 4. The statin medication to the client diagnosed with atherosclerosis.

1, 3, and 4 are correct. Nitroglycerin tablets are vasodilators that are administered to dilate the coronary vessels and provide oxygen to the heart muscle. The nurse should assess the client's vital signs as part of the assessment of the client's current situation. Supplemental oxygen will assist in getting higher concentrations of oxygen to the heart muscle.

While ambulating in the hallway with the nurse, the client diagnosed with myocardial infarction complains of chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer nitroglycerin 0.4 mg sublingual STAT. 2. Have the client walk back to the room. 3. Take the client's vital signs. 4. Place the client on supplemental oxygen. 5. Ask the ward secretary to call the healthcare provider for orders.