1
A nurse is completing an incident report after finding a client lying on the floor. Which following information is appropriate for the nurse to include?
1) The client attempted to climb over the side rails and fell.
2) The client was lying on the floor next to his bed.
3) The client was restless and trying to get out of bed all evening.
4) The presence of a bed alarm could have prevented the client from falling.
2) The client was lying on the floor next to his bed.
Answer Rationale:
In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident.
Define Contusion?
Contusion is a bruise
A nurse plans to leave her scheduled shift an hour early without permission and without notifying the charge nurse. The clients assigned to the nurse are in stable condition. The charge nurse should identify this behavior as which of the following legal torts?
1) Negligence
2) Libel
3) Battery
4) Slander
1) Negligence
Answer Rationale:
The nurse's conduct displays negligence, which is providing client care below the standard of care and placing the client at risk for harm. The nurse could face charges of client abandonment
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
1) Perform passive range of motion on each extremity.
2) Monitor the client's electrolyte levels.
3) Suction saliva from the client's mouth.
4) Record the client's intake and output.
3) Suction saliva from the client's mouth.
Answer Rationale:
The greatest risk to the unconscious client is inability to independently maintain a clear airway. The client is at risk for ineffective airway clearance; therefore, the priority nursing action is to maintain the client's airway.
Sodium
135-145
A nurse assigned care for a group of clients is planning to delegate tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to perform?
1) Obtaining a client’s weight
2) Applying antiembolic stockings
3) Observing a client’s sacrum for edema
4) Emptying a closed suction drainage device
3) Observing a client’s sacrum for edema
Answer Rationale:
The nurse should complete any task that requires the application of the nursing process, such as assessment. This may not be delegated to an AP as it is outside the AP’s scope of practice.
A nurse is assisting with the care of a group of pediatric clients. Which of the following actions should the nurse take first?
1) Provide clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy.
2) Administer acetaminophen to a child who has a temperature of 101.2º F (38.4ºC).
3) Complete pin site care to a child who is in skeletal traction.
4) Deliver a breakfast tray to a child who has been administered regular insulin.
4) Deliver a breakfast tray to a child who has been administered regular insulin.
Answer Rationale:
The nurse should recognize that the greatest risk to this client is the development of hypoglycemia following the administration of insulin; therefore, the priority action for the nurse to take is to deliver the breakfast tray.
A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
1) "Delegate simple tasks prior to evaluating the client’s condition."
2) "Delegated tasks require follow-up to ensure compliance."
3) "Observe delegated tasks directly during task performance."
4) "Delegate tasks such as vital signs regardless of the client’s condition."
2) "Delegated tasks require follow-up to ensure compliance."
Answer Rationale:
The nurse should include using of the five rights of delegation when assigning tasks to an AP, including the right task, right circumstances, right person, right communication, and right supervision. This last right, supervision, requires the nurse to appropriately monitor, evaluate, and provide feedback to the AP
What does a speech therapist do?
A speech therapist assesses and makes recommendations for clients experiencing speech, language, and swallowing difficulties.
Calcium
9-10.5
A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
1) Measure the output from a client’s indwelling urinary catheter.
2) Evaluate a client’s pain level 30 min after receiving an oral analgesic.
3) Reinforce foot care to a client who has a new diagnosis of diabetes mellitus.
4) Administer an enteral feeding to a client who has a new gastrostomy tube.
1) Measure the output from a client’s indwelling urinary catheter.
Answer Rationale:
Measuring the output from a client’s indwelling urinary catheter does not require use of the nursing process, but does require knowledge and skill that is within the scope of practice of the AP.
What does an occupational therapist do?
Occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movement to complete self care.
A nurse in a long-term care facility is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign the AP?
1) Reinforcing teaching regarding bathing with a client
2) Attending to a client who has fallen out of bed
3) Initiating an enteral tube feeding
4) Educating a client on the use of an incentive spirometer
2) Attending to a client who has fallen out of bed
Answer Rationale:
The AP should attend to a client who has fallen out of bed to prevent further injury and call for help. This is within the AP’s scope of practice.
A nurse is performing care for several clients with the help of an assistive personnel (AP). Which task should the nurse ask the AP to perform first?
1) Take an ABG specimen to the laboratory.
2) Transport a client to the radiology department for an x-ray.
3) Obtain a routine urine sample from a client right after admission.
4) Give fresh water to each client who does not have NPO status.
1) Take an ABG specimen to the laboratory.
Answer Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines that the AP’s priority task is to take the ABG specimen to the laboratory because it is essential for determining the client’s respiratory status. Processing of this specimen is also urgent because it will deteriorate without placing it on ice and transporting it immediately.
potassium
3.5-5
A nurse is planning care for a group of clients. Which of the following tasks should the nurse assign to the assistive personnel (AP)?
1) Assist a client who is 1 day postoperative following an open cholecystectomy to ambulate.
2) Record a client’s vital signs during a blood transfusion.
3) Offer a pamphlet about advance directives to a newly admitted client.
4) Ask a client whether pain was relieved after administration of acetaminophen.
1) Assist a client who is 1 day postoperative following an open cholecystectomy to ambulate.
Answer Rationale:
The AP should provide care to stable clients. Assisting a stable client with ambulation is appropriate for the AP. Additionally, the AP skill level includes obtaining vital signs, providing hygiene care, feeding, and limited non-sterile procedures. A client who is 1 day postoperative following an open cholecystectomy should be stable. This is an appropriate task to delegate to the AP.
T/F: The student nurse should enroll in a review course that comes in a DVD and the instructor is accessible by e-mail?
FALSE! A course that offered by recording and no instructor present is not likely to be worthwhile exercise.
A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?
1) Speaks in short phrases
2) Use of accessory muscles to breathe
3) Increased sputum production
4) Pulse oximetry reading of 90%
1) Speaks in short phrases
Answer Rationale:
When using the urgent vs nonurgent approach to client care, the nurse determines that the priority finding is an inability to talk normally or to complete a sentence without becoming short of breath; this indicates that the client is having a difficult time maintaining oxygen status and saturation. Other signs of rapidly decreasing oxygen saturation include cyanosis and mental confusion or a change in mental status. This client is considered unstable. This client requires the scope of practice of the RN.
Who should the nurse see first?
- a pt wanting a shower
- pt wanting a referal to home health
- pt who is on a PCA (Patient controlled analgesia) pump which contains morphine
-Pt who has questions on a new medication
- pt who is on a PCA (Patient controlled analgesia) pump which contains morphine
Phosphorus
3-4.5
A nurse is caring for a client who is experiencing dysphagia. Which of the following referrals should the nurse request at this time?
1) Speech therapist
2) Social worker
3) Registered dietitian
4) Occupational therapist
1) Speech therapist
Answer Rationale:
A speech therapist assesses and makes recommendations for clients who are experiencing speech, language, and swallowing difficulties. It would be appropriate for a client who has dysphagia to be referred to a speech therapist for a swallowing evaluation.
A newly licensed nurse is providing assistance during a mass casualty. Place the clients in order from highest to least priority.
1. A client with an open fracture with distal pulses
2. A client with massive head trauma and agonal breathing
3. A client with contusions to the extremities
4. A client with an airway obstruction
4. A client with an airway obstruction
1. A client with an open fracture with distal pulses
3. A client with contusions to the extremities
2. A client with massive head trauma and agonal breathing
Nurse finds out they have made a medication error. What sequence should the nurse follow?
- Notify the risk manager.
- Check vital signs.
- Instruct the client to remain in bed until further notice.
- Call the provider.
- Complete an incident report
1. Check pt vital signs
2. Instruct client to remain in bed until further notice.
3. Call the provider
4. Complete an incident report
5. Notify the risk manager (Risk manager reviews and assesses risk to change policies and protocol and what can be done to prevent mistakes.)
A nurse is monitoring a client receiving packed RBCs. The nurse notices facial flushing, and the client reports lower back pain. Which of the following actions is the priority for the nurse to take?
1) Infuse 0.9% sodium chloride solution.
2) Insert an indwelling urinary catheter.
3) Send the blood and tubing to the laboratory.
4) Stop the transfusion.
4) Stop the transfusion.
Answer Rationale:
The greatest risk to this client is further injury from a blood transfusion reaction; therefore, the priority action for the nurse to take is to stop the transfusion. Even a small additional amount of blood can worsen the client’s reaction, so the nurse should stop the transfusion immediately.
What medication class is lisinopril
Ace inhibitor