Nursing Process, Roles, & Delegation
You are collecting a client's health history and current medications. Which step of the nursing process are you performing?
What is Assessment?
A nurse's hands are not visibly soiled before routine client care. What is an appropriate method of hand hygiene?
What is alcohol-based hand rub?
A client who has had vomiting and diarrhea for two days has a blood pressure of 87/55 mm Hg. This is the most likely reason for the client’s abnormal blood pressure.
What is fluid volume loss/dehydration?
In the acronym RACE, what does the R stand for?
What is Rescue/Remove clients from immediate danger?
A wound produces thick, yellow-green drainage. How should the nurse describe this drainage?
What is purulent drainage?
A client has pneumonia and needs assistance mobilizing respiratory secretions. Which interdisciplinary team member should the nurse expect to collaborate with?
Who is the respiratory therapist?
A client with suspected C. difficile has frequent diarrhea. After providing perineal care and removing gloves, what should the nurse do before leaving the room?
What is wash hands with soap and water?
An AP reports a client's pulse as 76/min. When the nurse assesses the client, the rhythm feels irregular. What should the nurse do next?
What is auscultate the apical pulse for one full minute?
An older adult is confused and repeatedly tries to stand without assistance. Before considering restraints, name an appropriate safety intervention.
What is using a chair/bed alarm, frequent observation, room change, and reorientation?
How should the nurse handle soiled linen?
What is hold away from the body and discard in the hamper immediately after removal?
An AP reports that a previously stable client's BP is 86/50 mm Hg. What should the RN do first?
What is assess the client and verify the abnormal finding?
A client with influenza needs to leave the room for a chest x-ray. What infection-control action is most important during transport?
What is placing a surgical mask on the client?
A client has an SpO₂ of 89%, is awake, and is breathing shallowly while lying nearly flat. What should the nurse do first to improve oxygenation?
What is raise the head of the bed/reposition upright and encourage deep breathing?
A hospitalized client begins having a tonic-clonic seizure while in bed. What should the nurse do to reduce the risk of aspiration?
What is turn the client to the side?
An immobile client cannot independently clear oral secretions during oral care. How should the nurse position the client to reduce aspiration risk?
What is side-lying?
A newly admitted client requires a comprehensive assessment. Can the RN delegate this assessment to an LPN? Provide the rationale.
What is No?
The RN performs the initial assessment.
The nurse is assigned clients with measles, influenza, and an MRSA wound. Match each client to the required transmission-based precaution.
What are measles - airborne; influenza - droplet; MRSA wound - contact?
A 8-month-old infant requires a postoperative pain assessment. Which pain scale is appropriate?
What is the FLACC scale?
An older adult reports getting dizzy when walking to the bathroom at night. Which change would best reduce fall risk while preserving independence?
What is provide a bedside commode/assistive toileting option?
A client produces 90 mL of urine over 4 hours. What should the nurse recognize?
What is urinary output is below the expected minimum?
The nurse delegates ambulation of a stable client to an AP. The AP reports that the client became dizzy and weak. What responsibility remains with the RN?
What is assessing the client and determining the appropriate nursing response?
A nurse enters the room of a client with tuberculosis wearing gloves, a gown, and a surgical mask. Which part of the PPE selection requires correction?
What is replace the surgical mask with an N95 respirator?
A client is laughing, texting, and visiting with family but reports 10/10 pain and requests prescribed pain medication. Despite the client’s appearance, this principle should guide the nurse’s response.
What is pain is subjective and the client’s self-report is the most reliable indicator of pain?
A restrained client is increasingly restless. Assessment reveals cool fingers and delayed capillary refill distal to the restraint. What is the nurse's priority action?
What is release the restraint immediately?
A client begins a 24-hour urine collection at 0700, voids at 0700, and asks the nurse to save that urine. What should the nurse instruct the client to do?
What is discard the 0700 specimen, note the start time, and collect subsequent urine for 24 hours?