The nurse is preparing assignments for the day shift. It is most important that the client with which diagnosis and description is assigned to a
... [Show More] registered nurse?
A. Menorrhagia: 24 hours post vaginal hysterectomy
B. Myocardial infarction: 4-days post infarction, transferred from ICU yesterday
C. Depression: Admitted during the night, following a suicide attempt with an overdose of Tylenol
D. Pneumonia: A 4-year old who is receiving IV antibiotics
C. Depression: Admitted during the night, following a suicide attempt with an overdose of Tylenol
During report, the charge nurse informs a nurse that she must work on another unit. The nurse begins to sigh deeply and tosses about her belongings as she is preparing to leave, making it known that she is very unhappy about having to "float." What is the best immediate action for the charge nurse to take?
A. Continue with report, and talk to the nurse about the incident at a later time
B. Ask the nurse to call the supervisor to see if she can be reassigned
C. Stop report and remind the nurse that all staff must "float" at some time
D. In the presence of other staff members, inform the nurse that her behavior is inappropriate
A. Continue with report, and talk to the nurse about the incident at a later time
A 15-year-old sexually active girl diagnosed with pelvic inflammatory disease (PID) is admitted to the hospital with a temperature of 101.6F and a purulent vaginal discharge. She has no insurance and tells the nurse she enjoys small children. Which room should the nurse assign this client?
A. A semi-private room with a 4-year-old girl who is currently receiving chemotherapy
B. A semi-private room with an older adolescent girl who had surgery yesterday
C. A room close to the nurse's station
D. A private room
D. A private room
The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to provide care for a bedfast client needing total care, medications, and Foley catheter irrigation. How should the RN assign the client's care?
A. UAP: Personal care, catheter irrigation, I&O. RN: Medications
B. UAP: Personal care. RN: Medications, catheter irrigation, I&O
C. UAP: Catheter irrigation, I&O. RN: Medications. Both provide personal care.
D. UAP: Personal care, I&O. RN: Catheter irrigation, medications.
D. UAP: Personal care, I&O. RN: Catheter irrigation, medications.
The charge nurse assigns the care of a client with diabetes who has hyperglycemia to a practical nurse (RN). In supervising the PN, what is the charge nurse's most important action?
A. Decide which sliding scale insulin dose should be administered
B. Obtain the blood sugar results via skin puncture and glucometer
C. Notify the healthcare provider of the daily serum glucose results
D. Confer with the PN about any manifestations the client is exhibiting
D. Confer with the PN about any manifestations the client is exhibiting
A registered nurse (RN) is caring for several clients on a progressive care "step-down" unit. After assessing the clients, which clerical tasks should the nurse assign to a UAP?
A. Chart pulse oximeter readings and type of breath sounds auscultated in the medical record.
B. Record the presence of blood-tinged urine and the hourly Foley output on the flow sheet.
C. Document the type and amount of drainage on a new surgical dressing in the progress note.
D. Transcribe vital signs from a unit worksheet to the individual graphic page in the client charts.
D. Transcribe vital signs from a unit worksheet to the individual graphic page in the client charts.
Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital?
A. The case manager notifies the family that the critical pathway requires transfer to a hospice facility.
B. The case manager notifies the social worker of the client's financial needs related to hospice care
C. The social worker describes the client's feelings of grief to the spiritual counselor
D. The social worker provides information about long-term care facilities to the client
A. The case manager notifies the family that the critical pathway requires transfer to a hospice facility.
The UAP reports morning vital signs to the primary nurse. Which client should the nurse assist first? The client who is:
A. diagnosed with myxedema with a temperature of 96.8F
B. one-day postoperative abdominal surgery with a pulse of 104 beats/minute
C. diagnosed with hypertension and has a blood pressure of 154/94 mmHg
D. diagnosed with pneumonia and has a respiratory rate of 26 breaths/minute
D. diagnosed with pneumonia and has a respiratory rate of 26 breaths/minute
A female client is receiving an enteral feeding via nasogastric feeding tube. The daughter reports to the charge nurse that her mother is coughing vigorously and sounds congested. Which staff member should the charge nurse ask to check on the client?
A. Registered nurse (RN) who is admitting a new postoperative client to the unit
B. Practical nurse (PN) who is giving routine medications
C. Practical nurse (PN) who is talking with anxious family members
D. Registered nurse (RN) who is entering nursing notes at the computer
D. Registered nurse (RN) who is entering nursing notes at the computer
The charge nurse, along with two registered nurses (RN), one practical nurse (PN), and one UAP is working in an emergency department. What activity should be assigned to the UAP?
A. Monitor a client with mid-sternal chest pain, nausea, and vomiting
B. Give instructions to the EMS about a patient being transferred to a nursing home
C. Transport a client diagnosed with septicemia to the medical unit
D. Obtain the history from a female client who presents in early labor
C. Transport a client diagnosed with septicemia to the medical unit
The charge nurse working in a long-term care facility is informed by the LPN that a client's son is unhappy with the care his mother is receiving. What action should the nurse take first?
A. Ask the family member to come to the nurses' station to discuss the concerns
B. Provide the son with a complaint form and ask him to describe the situation
C. Discuss with the LPN the son's concerns about his mother's care
D. Notify the administrator of the long-term care facility about the son's discontent
C. Discuss with the LPN the son's concerns about his mother's care
When the charge nurse is making assignments, which tasks can be assigned to a UAP?
A. Perform a dressing change, oral suctioning, and admission of a client to the unit
B. Time contractions, determine fetal heart rate, and administer an enema to a client in early labor
C. Take vital signs, give a cleansing enema, and apply soft restraints to an older client
D. Irrigate a naso-gastric tube, collect a stool specimen, and measure intake and output
C. Take vital signs, give a cleansing enema, and apply soft restraints to an older client
The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystitis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client?
A. A private room fully equipped with an outside air ventilation system
B. A semi-private room shared with a bed-ridden elder who would enjoy the company
C. A semi-private room with a bed available nearest to the bathroom
D. A semi-private room that does not have a client in the other bed at this time
D. A semi-private room that does not have a client in the other bed at this time
A nurse who works in an acute minor illness clinic returns form lunch and finds several clients who need attention. Which client should the nurse attend to first?
A. A 10-year-old with asthma who is responding well to nebulizer treatments
B. A three-week-old infant who is nursing and was brought in because he had a fever
C. A 4-year-old receiving intravenous fluid for dehydration whose IV fluid bag is empty
D. A 6-year-old with Down syndrome who has been coughing productively
C. A 4-year-old receiving intravenous fluid for dehydration whose IV fluid bag is empty
The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan?
A. Do not allow those with influence to be admitted to the unit
B. Require that all clients receive a pneumonia vaccine prior to admission
C. Ensure that sterile technique is followed when changing surgical dressings
D. Encourage clients to drink water to prevent urinary tract infections
C. Ensure that sterile technique is followed when changing surgical dressings
The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make?
A. 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os.
B. 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions.
C. 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP.
D. 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.
B. 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions.
An emergency room anticipates an influx of injured clients from a large motor vehicle collision on a major freeway. Which client should the triage nurse send to the trauma staff for immediate intervention?
A. A young adult male with a suspected closed head injury who has no respirations despite having his airway repositioned by the emergency medical team.
B. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway
C. A teenager with a suspected fractured leg who's respirations are 26 breaths/minute, capillary refill
D. A young adult with a facial laceration that is controlled by pressure and whose respiratory rate, capillary refill, and ability to follow commands are WNL
B. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway
Which pediatric client requires immediate intervention by the nurse?
A. A 2-year-old with a twenty-four hour urine output of 500mL
B. A 3-year-old with several episodes of nocturnal enuresis
C. A 4-year-old with an easily palpable bladder and frequency
D. A 5-year-old with diuresis following furosemide (Lasix) administration
C. A 4-year-old with an easily palpable bladder and frequency
The nurse is caring for 4 clients on an orthopedic floor: 2 clients with total hip replacements, one client with total knee replacement, and one client with a fractured femur who is in skeletal traction. Which nursing task should the nurse delegate to the UAP?
A. Adjust the setting on the continuous passive motion machine (CPM)
B. Clean the skeletal traction insertion sites while performing a.m. care
C. Assist the client to ambulate for the first time after surgery
D. Change the linens for the client with skeletal traction
D. Change the linens for the client with skeletal traction
The nurse is giving change-of-shift report for four clients in the emergency center and reports the client with a terminal disease has a living will and a "Do not resuscitate" (DNR) order on file. Which client fits the criteria for a terminal illness?
A. 2-year-old child with esophageal burns from drinking drain cleaner who now has a gastrostomy tube
B. 76-year-old female client with Alzheimer's disease who is pacing the halls and trying to "go home."
C. 52-year-old male client who had a partial lobectomy and on a ventilator on the 2 postoperative day
D. 43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration
D. 43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration
The nurse manager is talking to a new nurse who is thinking about resining before orientation to the unit is over. The nurse-manager explains that reality shock after graduation is common. Which explanation should the nurse-manager use to best describe reality shock to the new nurse?
A. A realization that practice and education are not the same
B. A series of experiences to become an experienced nurse
C. A period of role adjustment from school into the work force
D. A phase that new nurses go through before changing jobs
C. A period of role adjustment from school into the work force
Which task should the nurse delegate to the UAP?
A. Accompany the healthcare provider during client visits
B. Determine a client's response to pain
C. Observe a client's central venous catheter site
D. Feed a client with minimal dysphagia
D. Feed a client with minimal dysphagia
The nurse receives report in the emergency center for four clients. Which client should the nurse assess first?
A. A screaming child with a compounding fracture of the wrist
B. A diabetic client with a laceration on the sole of the foot
C. A client experiencing shortness of breath and dyspnea
D. A geriatric client with many new and old bruises noted
C. A client experiencing shortness of breath and dyspnea [Show Less]