Prioritization
A patient with DM II states she is having a hypoglycemia episode. The nurse priority action is to______?
a. Complete a bedside glucose check (BG)
b. Administer subcutaneous glucogon
c. Administer dextrose Intravenously
d. Give a cup of orange juice
Complete a bedside glucose check
Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? (select all that apply)
a.Perform mouth care on the client diagnosed with pneumonia
b. Apply oxygen via nasal cannula to the client
c. Empty the trash cans in the client’s rooms
d. Take the empty blood bag back to the laboratory
e. Show the client how to ambulate on the walker
A, C, D,
The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement (Select all that apply)
a. Continue to care for the client’s needs as usual
b.Place a DNR identification armband on the client
c. Refer the client to a hospice organization
d. Limit visitors to two at a time, so as not to tire the client
e. Remove telemetry monitors from the client
A, B,
Test-takin strategies in Nursing assist in selecting the right answer?
True or False
False
The nurse is administering medications on a neurological unit. Which medications should the nurse administer first?
a. The osmotic diuretic to the client diagnosed with a closed head injury
b. The morning medications to the client scheduled for physical therapy
c. The narcotic pain medication to a client diagnosed with increased intracranial pressure
d. Gabapentin to the client diagnosed with restless leg syndrome
A. The osmotic diuretic to the client diagnosed with a closed head injury
The clinical nurse is assessing a client who is reporting right leg calf pain. The right calf is edematous and warm to the touch. Which intervention should the nurse implement first?
a. Notify the HCP immediately
b. Ask the client how long his calf has been hurting
c. Complete a neuromuscular assessment on his leg
d. Place the client's right leg on two pillows
Notify the HCP immediately
The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide to the LPN?
a. Administer the prescribed tetanus toxoid vaccine
b. Assess wounds for signs of infection
c. Encourage the client to cough and deep breath
d. Wash hands on entering clients room
D. Wash hands on entering clients room
The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse?
a. The client whose INR is 2.3
b. The client whose H&H is 11 g/dL and 36%
c. The client whose platelet count is 65, 000 per mL of blood
d. The client whose red blood cell count is 4.8 x 106 cells/micro L
C. The client whose platelet count is 65, 000 per mL of blood
If objective assessment is in the questions you would ________?
a. Initiate an intervention
b. Reassess for validation of data
c. Delegate to a UAP or LPN
d. Implement the nursing process
A. Initiate an intervention
Which medication will the nurse be prepared to administer to a client with bradycardia as a result of hypothyroidism?
a. Atropine sulfate
b.Levothyroxine sodium (Synthroid)
c. Propranolol (Inderal)
d. Epinephrine
B. Levothyroxine sodium (Synthroid)
The unlicensed assistive personnel (UAP) tell the RN staff 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?
a. Have the UAP recheck the clients vital signs
b. Assess the clients' cardiovascular status
c. Notify the HCP immediately
d. Place the client in trendelenburg position
Assess the clients' cardiovascular status
The nurse is caring for a client with a nasogastric (NG) tube. Which task can be delegated to an experienced unlicensed assistive personnel (UAP)?
a. Removing the NG tube at the prescribed time
b. Securing the tape if the client accidentally dislodges the tube
c. Disconnecting the suction to allow ambulation to the toilet
d. Reconnecting the suction after the client has ambulated
C. Disconnecting the suction to allow ambulation to the toilet
Which assessment finding best indicates that treatment with levothyroxine (Synthroid) has been successful?
a. The client is thirsty
b. The client’s weight has been the same for 3 weeks.
c. The client’s total white blood cell count is 6000 cells/mm3.
d. The client’s heart rate is 70 beats/min
D. The client’s heart rate is 70 beats/min
When an answer has, "only", "always, "never", "forever then it is a good answer.
True or False
False
A 67-year-old female patient is admitted to the Emergency Department (ED) for slurred speech, altered mental status (AMS), and left-side weakness. The client has a past medical history of Atrial Fibrillation (AFib) treated with Coumadin (Warfarin) 2.5 mg PO daily. The MRI is positive for a right cerebral infarction. The healthcare provider (HCP) orders alteplase (Activase) 0.9 mg/kg IV bolus for 60 seconds and continue infusion for 60 minutes. The nurse’s next action would be:
a. Administer HCP orders of alteplase (Activase) 0.9 mg/kgIV bolus
b. Assess the clients’ 20-gauge peripheral intravenous (PIV) catheter site for patency
c. Review the clients am PT/INR lab values
d. Initiate a phone call to the HCP regarding the order of alteplase (Activase)
C. Review the clients am PT/INR lab values
Which nursing intervention is the priority for the intensive care nurse to implement when caring for a client diagnosed with diabetic ketoacidosis (DKA)?
a. Assess for fruity breath odor
b. check blood glucose levels ac and hs
c. Monitor the client's pulse oximeter readings
d. Maintain the regular insulin IV rate on an infusion pump
Maintain the regular insulin IV rate on an infusion pump
The nurse is caring for a client who had a right-sided stroke 5 days ago and is experiencing unilateral neglect. In delegating for the care of the client, which nursing intervention is of PRIORITY? The nurse instructs the nursing assistant to:
a. Have the client use a communication board
b. Place the food tray to the right side of the body
c. Remind the client to look at the left side of the body
d. Provide passive range of motion to the left side of the body
B. Place the food tray to the right side of the body
A client was admitted to the emergency department (ED) with a thermal burn to the right arm and upper and lower leg. Which assessment by the nurse requires immediate action?
a. Coughing and bilateral wheezing
b. Bright red skin with small blisters on the burn sites
c. Complaints of thirst
d. Singed hair on bilateral lower extremities
A. coughing and bilateral wheezing
The NCLEX strategy of A, B, C mean_________?
a. Airway, Breathing, Circulationb. Airway, Breaths per minute, Cardiovascular
c. Always intervene, Breathing, Circulatory
d. Airway, Bilateral, Cardiovascular Circulation
A. airway, breathing, circulation
What pharmacological treatment would the nurse administer aimed at prevention of pulmonary embolism (PE)?
a. Streptokinase
b. AquaMEPHYTON (vitamin K)
c. Enoxaparin
d. Protamin sulfate
C. Enoxaparin
Which client warrants immediate intervention by the nurse?
a. The client diagnosed with pericarditis who has chest pain with inspiration
b. The client diagnosed with mitral valve regurgitation who has a thready peripheral pulse
c. The client diagnosed with Marfan syndrome who has pectus excavatum
d. The client diagnosed with atherosclerosis who has slurred speech and
The client diagnosed with atherosclerosis who has slurred speech and
The nurse is caring for a client after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? (Select all that apply)
a.Assess puncture site and dressing for leakage
b. Check vital signs every 15 minutes for 1 hour
c. Auscultate for absent or reduced lung sounds
d. Remind the client to take deep breaths
e. Take the specimens to the laboratory
f. Teach the client the symptoms of a pneumothorax
B, D, E,
The nurse is caring for a client with severe burns who is receiving fluid resuscitation in the acute phase. Which of the following indicates that the client is responding to the fluid resuscitation?
a.Pulse rate of 112
b. Blood pressure 94/64
c. Urine output 30 mL/hr
d. Serum sodium level of 136 mEq/L
C. urine output 30 mL/hr
When an RN is delegating a task using the acronym EAT, it stands for _______ ?
a. Evaluation, Accept, Take vitals
b. Evaluate, Assess, Teach
c. Evaluation initial, Assessment, Total Care
d. Evolution, Assessment, Time
B. evaluate, assess, teach
A client recently diagnosed with hypothyroidism demonstrates understanding of prescribed levothyroxine medication when she makes which statement?
a. “I should be able to become pregnant in a couple of months.”
b. “This medication will help me lose all this excess weight.”
c. “I should call the physician for nervousness, diarrhea, or increased pulse.”
d. “This medication should be taken with food, preferably dairy products.”
C