Pri
A nurse is assisting with planning care for a group of patients. Which of the following actions should the nurse plan to take?
A. Delegate the administration of an intermittent tube feeding to a second LPN
B. Assign an assistive personnel (AP) to monitor a patients dressing for evidence of bleeding
C. Ask an AP to explain to a patient how to empty a urinary bag
D. Delegate the administration of a unit of packed RBCs to a second LPN
A. Delegate the administration of an intermittent tube feeding to a second LPN
b. not in scope of an AP
c. AP not responsible for teaching
d. not in LPN scope
A nurse is prioritizing care for a group of patients. The nurse should plan to attend to which of the patients first?
A. A patient who requires a sterile dressing change
B. A patient who requires a gastrostomy tube feeding
C. A patient who requires urinary catheter care
D. A patient who requires endotracheal suctioning
D. A patient who requires endotracheal suctioning
A nurse enters a patient's room and finds the patient lying on the floor next to the bed. Which of the following actions should the nurse take first?
A. Determine the cause of the accident
B. Check the patient for injuries
C. Call for assistance to get the patient back in the bed
D. Complete an incident report
B. Check the patient for injuries
A nurse is assisting with the preoperative preparation of a patient who is scheduled for surgery. Which of the following tasks can the nurse delegate to the assisted personnel (AP)?
A. Verify the patient's list of allergies in the medical record
B. Assist with placing the patient onto the stretcher for transport to the surgical suite
C. Complete the preop checklist for the patient
D. Call the provider about the patient's elevated blood glucose level
B. Assist with placing the patient onto the stretcher for transport to the surgical suite
A nurse is selecting patients for discharge following an environmental disaster. Which of the following patients should the nurse select?
A. A patient who had cast removal due to compartment syndrome
B. A patient who is scheduled for dialysis and has a potassium level of 6.2 mEq/L
C. A patient who has type 1 diabetes and a blood glucose of 320 mg/dL
D. A patient who is 1 day post-op following an inguinal hernia repair
D. A patient who is 1 day post-op following an inguinal hernia repair
this pt is stable, the others need more monitoring
A charge nurse is making the daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
A. Measuring vital signs
B. Reinforcing an IV catheter's dressing
C. Preoperative admission assessment
D. Showing a patient how to use a walker
A. Measuring vital signs
within scope of practice, the other three answers are not
A nurse on a medical-surgical unit is planning care for a group of patients. Which of the following patients should the nurse attend to first?
A. A newly admitted patient who is scheduled to have an indwelling urinary catheter inserted
B. A patient who has kidney stones and reports flank pain of 6 on a scale of 0 to 10
C. A patient diagnosed with early stage chronic kidney disease who has a serum creatinine level of 2.0 mg/dL
D. A patient who has a cast newly applied on the forearm and reports tingling of the fingers
D. A patient who has a cast newly applied on the forearm and reports tingling of the fingers
may indicate compartment syndrome which is increased tissue pressure in a confined anatomical space reducing blood flow, leading to ischemia, dysfunction, and eventual necrosis
A charge nurse on a medical-surgical unit is making patient assignments for the oncoming shift. Which of the following patients should the charge nurse assign to an LPN?
A. A patient who requires an update to the plan of care following a diagnosis of cancer
B. A patient who is postoperative following a total hip replacement and requires discharge teaching
C. A patient who has a prescription for irrigation of an indwelling urinary catheter
D. A patient who has just arrived from PACU and requires a head-to toe assessment
C. A patient who has a prescription for irrigation of an indwelling urinary catheter
this is within the scope of practice, the other answers are NOT w/i scope of practice
A nurse manager observes a nurse entering the room of a patient who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority action for the nurse manager to take?
A. Speak with the nurse in a private location
B. Complete an incident report
C. Review competencies with the staff regarding PPE
D. Have the nurse exit the room and don proper PPE
D. Have the nurse exit the room and don proper PPE
nurse manager should first ensure the safety of the staff and patients by having the nurse exit the room and apply proper PPE
A charge nurse finds an increased incidence of health care - associated infections (HAIs) on a long-term care unit. Which of the following actions is the charge nurse's priority?
A. Monitor the staff's hand hygiene techniques
B. Hold a mandatory in-service session about hand hygiene and infection rates
C. Require nurses to take an online course on HAIs
D. Conduct a chart review to gather data about patients who developed HAIs
D. Conduct a chart review to gather data about patients who developed HAIs
first step in nursing process in to collect data by conducting a chart review
A charge nurse on a medical-surgical unit is assigning patient care for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply)
A. Performing colostomy care
B. Measuring a patients intake and output
C. Interpreting a patient's laboratory values following surgery
D. Providing postmortem care to a patient
E. Checking nasogastric tube patency
B & D
Within their scope of practice
A = requires data collection, outside scope of practice
C & E outside scope of practice
The nurse is collecting data from a patient who has recently been prescribed lithium carbonate. Which of the following is the nurse's priority?
A. Fine hand tremors
B. Weight gain of 2.7 kg (6lb.)
C. Report of nausea
D. Poor motor coordination
D. Poor motor coordination
using urgent vs. non-urgent approach, must recognize poor motor coordination is an advanced manifestation of lithium carbonate toxicity
the other 3 answers are expected findings of patients who have recently been prescribed lithium
A charge nurse is providing teaching to a new staff nurse regarding delegation to assistive personnel (AP). Which of the following pieces of information should the charge nurse include in the teaching?
A. The nurse can delegate the task of teaching a patient about foot care to an AP
B. The nurse should be familiar with the task he/she plans to delegate
C. The person who accepts the delegated task also assumes accountability for the task
D. The AP should report to the nurse any tasks that he/she further delegates to other APs
B. The nurse should be familiar with the task he/she plans to delegate
APs cannot teach
accountability remains with the nurse who delegated the task
AP does not have authority to delegate other APs
A nurse is caring for a group of patients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Select all that apply.
A. Collecting a stool specimen
B. Providing instructions about using a spirometer
C. Measuring oral intake
D. Providing postmortem care
E. Changing a sterile dressing
A, C & D
all within scope of practice
cannot provide instructions/education
sterile dressing requires an assessment which is outside scope of practice
A nurse enters a patient's room and notices a small fire in a trash can. Which of the following actions should the nurse take first?
A. Place moist towels or blankets at the threshold of the door of the room with the fire
B. Close fire doors and patient room doors
C. Pull the fire alarm and notify the facility operator
D. Move the patient out of the room
D. Move the patient out of the room
the priority is to remove patient from room to ensure safety of the patient
A nurse is interviewing a patient who has a new diagnosis of major depression. Which of the following questions is the nurse's priority?
A. "Have you thought about hurting yourself"
B. "What has been troubling you"
C. "Do you have anyone who can offer you support"
D. "When did you start to feel bad"
A. "Have you thought about hurting yourself"
Patient at risk for suicide therefore priority is asking patient if they thought about hurting themself
A nurse is preparing an IM injection for a patient who is preoperative when another patient suddenly calls for assistance. The nurse asks another nurse to give the injection because an assistive personnel is waiting to take the patient to surgery. Which of the following actions should the second nurse take?
A. Prepare a new syringe for the patient who is preoperative
B. Give the prepared medication to the patient who is preoperative
C. Help the other patient requesting assistance so that the first nurse can give the prepared injection
D. Report this request to the charge nurse
C. Help the other patient requesting assistance so that the first nurse can give the prepared injection
the nurse who prepared medication is the only one who can safely identify what is in the syringe and be responsible for the correct administration of the med
A nurse is planning to delegate the postoperative care of a patient following an appendectomy. Which of the following actions should the assign to an assistive personnel (AP)?
A. Showing the patient how to use the patient-controlled analgesia pump
B. Recording urinary output after emptying the indwelling urinary catheter
C. Assisting the patient out of bed and into a chair for the first time after surgery
D. Checking the patient's abdominal dressing
B. Recording urinary output after emptying the indwelling urinary catheter
within scope of practice, task is routine and has a predictable outcome
other three answers are not within scope of practice
A nurse is reviewing the medication administration record for a patient and notes that the nurse from the previous shift gave double the dose of antihypertensive medication prescribed to the patient. Which of the following actions should the nurse perform first?
A. File an incident report with factual information about the error
B. Report the incident to the nursing supervisor
C. Check on the patient's condition
D. Notify the patient's provider about the incident
C. Check on the patient's condition
the greatest risk to the patient is an injury from a low BP d/t a double dose of anti-HTN meds therefore the priority is to check pt's VS
A nurse is caring for a group of patient's on a medical - surgical unit. Which of the following patient's should the nurse attend to first?
A. A patient who is receiving metoclopramide and reports diarrhea
B. A patient who is receiving tamsulosin and reports feeling dizzy
C. A patient who is receiving cephalexin and reports dyspnea
D. A patient who is receiving erythromycin and reports epigastric pain
C. A patient who is receiving cephalexin and reports dyspnea
the greatest risk to the patient is an injury from dyspnea d/t an allergic reaction from ATB - at risk for anaphylactic shock w/a compromised airway
A nurse receives a morning change of shift report and delegates several tasks to an assistive personnel (AP) on the team. Which of the following tasks should the nurse instruct the AP to perform first?
A. Obtain morning capillary blood glucose tests
B. Bathe a patient scheduled for physical therapy at 0900
C. Distribute the breakfast trays
D. Fill water pitchers with fresh water and ice
A. Obtain morning capillary blood glucose tests
urgent vs. non-urgent - the most urgent is obtaining blood glucose to administer insulin
A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)?
A. Perform a simple dressing change
B. Interpret a patient's blood glucose reading
C. Provide advice when speaking to a patient's family member on the phone
D. Determine the effectiveness of a patient's urinary catheter
A. Perform a simple dressing change
within the APs scope of practice
A nurse is participating in an ethics committee meeting about a patient who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first?
A. Collect information related to the issue
B. Consider the possible choices of action
C. Make a decision regarding transplant recommendation
D. Justify the recommendation for or against a transplant
A. Collect information related to the issue
first step in ethical decision making is to identify the ethical issue - this step includes asking questions to define the issue and the complexities of the situation
A nurse is assisting with making assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
A. Instruct a patient on how to use a glucometer
B. Instilling lubricating eye drops for a patient
C. Evaluating the effectiveness of a patient's pain medication
D. Transferring a patient who is postoperative from a bed to a chair
D. Transferring a patient who is postoperative from a bed to a chair
tasks that nurse should delegate to an AP include transfers, ambulation, VS, and other simple procedures that do not involve assessment or teaching