1. A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP)
... [Show More] has no documented the client's blood glucose level. Which of the following actions should the charge nurse take first?
Determine if the AP has completed the assignment.
2. A client is scheduled for an outpatient colonoscopy+ which of the following actions is a nursing responsibility in the informed consent process?
Verify that there is a signed and witnesses consent form in the client's chart.
3. A nurse smells alcohol on the breath of an assistive personnel CAP) during report. Which of the following actions should the nurse take?
Report the situation to the nurse manager.
4. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24hr ago.
5. A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cystic fibrosis. Which of the following supports a diagnosis of cystic fibrosis?
Frothy stools.
6. When caring for an assigned group of clients, the nurse should wear gloves when
Performing oral hygiene.
7. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?
Contact security personnel to place the money in the facility safe.
8. A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration?
Subcutaneously.
9. A nurse is reinforcing teaching about car seat safety to the parents of a newborn, The nurse should instruct the parents to place the car seat in a?
Rear-facing position in the back seat.
10. A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations?
A hospital risk manager includes information from a client's medical record in
11. A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take?
Notify the charge nurse of the finding.
12. A nurse is caring for a full-term newborn who was circumcised 6 hours ago, which of the following findings indicates that the newborn is experiencing pain?
Furrowed Brow
13. A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching?
"My doctor should decide if my organs will be donated."
14. A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is the appropriate response?
"Let's talk with your doctor about other options."
15. A nurse is preparing to administer an IM injection to a client. To reduce the risk of needle stick injury, the nurse should?
Dispose of the used needle immediately in a puncture-proof sharps container.
16. A Nurse is contributing to the discharge plan for a client following surgery.
Which of the following findings indicate the need for an interdisciplinary care conference?
The client requires assistance to pay for dressing supplies.
17. A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first?
Elevate the head of the client's bed.
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18. A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?
Obtain verbal consent from the client while waiting for the parents to arrive.
b. Witness the signature of the client's parent when he arrives. c. Have the client's older sibling give consent if a parent is not available. d. Delay the procedure if the provider cannot contact the parents.
24.A nurse has delegated care to an assistive personnel. At the end of the shift, the Ap asks the nurse to enter data for her because the AP has forgotten her password and needs to leave, Which of the following actions should the nurse take?
Tell the AP to contact the IT department for charting assistance [Show Less]