Saunders NCLEX-RN Leadership Management Delegating & Prioritizing

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP), which is the best client for the LPN? 1.A client requiring frequent temperature checks 2.A client requiring assistance with ambulation every 4 hours 3.A client on a mechanical ventilator requiring frequent assessment and suctioning 4.A client with a spinal cord injury requiring urinary catheterization every 6 hours

A client with a spinal cord injury requiring urinary catheterization every 6 hours

The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? 1."Actual or life-threatening concerns are the priority." 2."Completing care in a reasonable time frame is the priority." 3."Time constraints related to the client's needs are the priority." 4."Obtaining the needed supplies to care for the client is the priority."

"Actual or life-threatening concerns are the priority."

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities

1.The acuity level of the clients 5.Client needs and workers' needs and abilities

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1.A client scheduled to receive a blood transfusion 2.A client with bladder cancer who will be receiving chemotherapy 3.A client newly diagnosed with diabetes mellitus scheduled for discharge 4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms.

2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

A client requiring abdominal wound irrigations and dressing changes every 3 hours

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? 1.A client requiring frequent ambulation 2.A client scheduled for a cardiac catheterization 3.A client requiring range-of-motion (ROM) exercises 4.A client with a 24-hour urine collection who is on strict bed rest

A client scheduled for a cardiac catheterization

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? 1.A primigravida client in the active stage of labor 2.A multigravida client who was admitted for induction of labor 3.A client who is not contracting but has suspected premature rupture of the membranes 4.A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used.

A client with diabetes mellitus who needs a fasting blood glucose level drawn The first dressing change for a client requiring twice-daily dressing changes A client being visited by the home health aide at 1030 A client requiring supervision of a dressing change A client requiring an admission assessment to home health care The second dressing change for a client requiring twice-daily dressing changes

A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? 1.Private room 2.Semiprivate room 3.4-bed ward room 4.Contact isolation room

Private room

The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? 1.Remove the IV catheter. 2.Apply a warm compress. 3.Check for a blood return. 4.Measure the area of infiltration.

Remove the IV catheter.

The nurse is developing a client care assignment for a group of unlicensed assistive personnel (UAPs). What is the nurse's first step in planning and assigning clients? 1.Determine what skills can be delegated. 2.Determine the years of experience of each UAP. 3.Determine how much supervision is required for each client assigned. 4.Determine how many clients the agency allows to be delegated to each UAP.

Determine what skills can be delegated.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1.A confused older client who requires feeding 2.A client who requires turning every 2 hours 3.A client admitted with dehydration who is on strict intake and output 4.A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 5.A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

1.A confused older client who requires feeding 2.A client who requires turning every 2 hours 3.A client admitted with dehydration who is on strict intake and output 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1.A client who has a tympanic temperature of 99.8°F 2.A client who has a regular radial pulse of 96 beats/minute 3.A client who has a supine resting blood pressure of 148/90 mm Hg 4.A client who has a peripheral (index finger) oxygen saturation percentage of 85%

A client who has a peripheral (index finger) oxygen saturation percentage of 85%

Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. 1.Assessment 2.Urinary catheterization 3.Endotracheal suctioning 4.Intramuscular medication administration 5.Subcutaneous medication administration 6.Intravenous push medication administration

2.Urinary catheterization 3.Endotracheal suctioning 4.Intramuscular medication administration 5.Subcutaneous medication administration

The nurse has received her client assignment for the day. Which client should the nurse check first? 1.A client experiencing severe pain 2.A client who is hearing voices in his head 3.A client who has just returned from surgery 4.A client who is in 4-point leather restraints

A client who has just returned from surgery

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 1.The 11-year-old with burns to 10% of both legs 2.The sobbing 10-year-old with an obvious fracture of the forearm 3.The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute 4.The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 1.Set priorities for the client. 2.Assess the client's readiness to learn. 3.Find out whether anyone lives with the client. 4.Use only 1 teaching method to prevent confusion.

Assess the client's readiness to learn.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift

A client with asthma who requested a breathing treatment during the previous shift

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client

Actual or life-threatening concerns

The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1.Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2.Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3.Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 4.Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr 5.Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92% 6.Client with white blood cell count of 2200 mm3 (2.2 × 109/L), temperature of 102°F (38.9°C), and blood pressure of 90/40 mm Hg

1.Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2.Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3.Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1.A client scheduled to receive parenteral nutrition 2.A client who requires assistance with ambulation every 4 hours 3.A client scheduled for discharge who needs teaching about medications 4.A client with bladder cancer who is scheduled for a cardiac catheterization

A client who requires assistance with ambulation every 4 hours

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used.

Check the client's blood glucose level. Give the client ½ cup (118 mL) of fruit juice to drink. Take the client's vital signs. Retest the blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, actions taken, and outcome.

The registered nurse (RN) is planning her client assignments for the day. She has a licensed practical nurse and an unlicensed assistive personnel (UAP) on her team. Which task should the RN delegate to the UAP? 1.Empty a client's urinary catheter bag. 2.Instruct a client on his new diabetic diet. 3.Teach a client how to check her blood glucose. 4.Evaluate a newly admitted client's home medications.

Empty a client's urinary catheter bag.

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. Which term describing this organizational chart should the vice president employ while talking with the employees? 1.Flat 2.Vertical 3.Circular 4.Horizontal

Flat

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? 1.Prepare the child for tracheotomy. 2.Prepare to administer epinephrine. 3.Prepare the child for a chest radiograph. 4.Assist the health care provider with intubation.

Prepare the child for a chest radiograph.

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? 1."As the manager, do you maintain control and make all decisions?" 2."As the manager, do you assume a passive, nondirective approach?" 3."As the manager, do you facilitate decision making within the group?" 4."As the manager, do you change style according to the needs of the group?"

"As the manager, do you assume a passive, nondirective approach?"

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1."Cushing's syndrome is caused by excessive amounts of cortisol." 2."Cushing's syndrome is caused by decreased amounts of aldosterone." 3."Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4."Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

"Cushing's syndrome is caused by excessive amounts of cortisol."

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1.Inspecting skin surfaces 2.Observing the client's behavior 3.Measuring the client's height and weight 4.Assessing the client's general appearance 5.Monitoring oral intake and urinary output

3.Measuring the client's height and weight 5.Monitoring oral intake and urinary output

The nurse manager is planning the clinical assignments for the day. Which staff members CANNOT be assigned to care for a client with herpes zoster? Select all that apply. 1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine

3.The nurse who never had chickenpox 5.The nurse who never received the varicella-zoster vaccine

The nurse is planning client assignments for the day. Which clients can be safely assigned to unlicensed assistive personnel (UAPs)? Select all that apply. 1.Client who is receiving chemotherapy and is in isolation 2.Client with anemia who is receiving a second unit of blood and needs assessment of vital signs 3.Client newly diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy 4.Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5.Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding 6.Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment

4.Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5.Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding

An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? 1.A child with a bleeding laceration 2.A 54-year-old woman with a fractured wrist 3.A 67-year-old woman with first-degree burns on her hands and arms 4.A 45-year-old man with chest pain, shortness of breath, and diaphoresis

A 45-year-old man with chest pain, shortness of breath, and diaphoresis

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

A client who requires urine specimen collections

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? 1.A client who requires teaching about an insulin pump 2.Completing an admission assessment on a newly admitted client 3.Administration of a new oral medication to a client with Alzheimer's disease 4.An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

Administration of a new oral medication to a client with Alzheimer's disease

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriatenursing action? 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the UAP to find out when the last pain medication was given to the client. 3.Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the unlicensed assistive personnel (UAP)? 1.Orient the client to the hospital surroundings. 2.Instruct the client on how to apply the eye drops. 3.Listen to the client express his frustration or loss. 4.Review hand washing and hygiene practices with the client.

Orient the client to the hospital surroundings.

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical (vocational) nurse, and 2 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1.The client who requires a 24-hour urine collection 2.The client with an abdominal wound requiring frequent wound irrigations 3.The older client requiring assistance with a bed bath and frequent ambulation 4.The client on a mechanical ventilator requiring frequent assessment and suctioning

The client with an abdominal wound requiring frequent wound irrigations

The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? 1.The client with severe pain related to osteoporosis 2.The client with hypokalemia related to diuretic therapy 3.The client with thrombocytopenia related to chemotherapy 4.The client with an elevated white blood cell count related to infection

The client with thrombocytopenia related to chemotherapy

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1.A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2.A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3.A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4.A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)

A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)

The nurse has received her client assignment for the day. Which client should the nurse care for first? 1.A client requiring a preoperative intravenous antibiotic 2.A client with emphysema who has shortness of breath after just ambulating 3.A client with serous drainage on an incisional spinal wound post laminectomy 4.A client with postoperative pain reported at 7 out of 10, with 10 being the worst

A client with postoperative pain reported at 7 out of 10, with 10 being the worst

The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? 1.Put on gloves. 2.Evaluate the client's visual acuity. 3.Place the client in a supine position. 4.Place a strip of pH paper in the lower sac of the client's affected eye.

Evaluate the client's visual acuity.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

Move the victim to a safe area away from the snake and encourage the victim to rest.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? 1.Place the client in a side-lying position. 2.Initiate wound care protocol for standardized ulcer care. 3.Meet with the wound specialist to identify measures to improve healing. 4.Determine which treatments would best meet the healing needs of the client.

Place the client in a side-lying position.

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an unlicensed assistive personnel (UAP)? 1.Determining if the client has consistently been medication compliant 2.Providing distraction for the client by engaging the client in a board game 3.Discussing the frequency and duration of the hallucinations with the client 4.Assisting the client in identifying any new stressors he or she may be experiencing

Providing distraction for the client by engaging the client in a board game

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriateinstruction should be given to the LPN? 1.Administer 1 more enema. 2.Stop administering the enemas. 3.Continue to administer enemas until the solution is clear. 4.Wait for 1 hour and then continue administering the enemas.

Stop administering the enemas.

When planning care, which client should the nurse assess first? 1.The client with a chest tube for a pneumothorax 2.The client who had a cholecystectomy 2 days earlier 3.The client who is receiving total parenteral nutrition and lipids 4.The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)

The client with a chest tube for a pneumothorax

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1."The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2."If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3."Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4."You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

"Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care."

The nurse has received the client assignment for the day. Which client should the nurse care for first? 1.The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2.The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3.The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4.The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1.Victim with an open fracture of the left lower extremity 2.Victim who is crying hysterically and complaining of pain in the right ankle 3.Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4.Victim with an apparent chest wall defect and asymmetrical chest wall movement

Victim with an apparent chest wall defect and asymmetrical chest wall movement