1 >>The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? ?
- (A) Assess the client for any adverse reactions.
- (B) Complete the incident or adverse occurrence report.
- (C) Administer the correct intravenous antibiotic medication.
- (D) Notify the client’s healthcare provider.
2 >>The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? ?
- (A) Instruct the UAP to obtain the client’s serum glucose level.
- (B) Request the LPN to change the central line dressing.
- (C) Ask the LPN to bathe the client and change the bed linens.
- (D) Tell the UAP to obtain urine output for the 12-hour shift.
3 >>Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? ?
- (A) Check the pulse oximeter reading for the client on a ventilator.
- (B) Take the client’s sterile urine specimen to the laboratory.
- (C) Obtain the vital signs for the client in an Addisonian crisis.
4 >>Which situation would prompt the healthcare team to utilize the client’s advance directive when needing to make decisions for the client? ?
- (A) The client with a head injury who is exhibiting decerebrate posturing.
- (B) The client with a C-6 spinal cord injury (SCI) who is on a ventilator.
- (C) The client in chronic renal disease who is being placed on dialysis.
- (D) The client diagnosed with terminal cancer who is mentally retarded.
5 >>The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? ?
- (A) Instruct the UAP to apply sequential compression devices to the client on strict bed rest.
- (B) Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray.
- (C) Request the UAP to prepare the client for a wound debridement at the bedside.
- (D) Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.
6 >>The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? ?
- (A) Systems that make it difficult for the nurses to do their job.
- (B) How unhappy the nurses are with their current pay scale.
- (C) Collective bargaining activity at a nearby hospital.
- (D) The number of medication errors committed by an individual nurse.
7 >>The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? ?
- (A) Obtain a bone density evaluation test on a female client older than 50.
- (B) Perform a spinal screening examination on all female clients.
- (C) Encourage the client to walk 30 minutes daily on a hard surface.
- (D) Discuss risk factors for developing osteoporosis.
8 >>The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheelchair. Which priority action should the HH nurse tell the HH aide? ?
- (A) Explain how to perform isometric exercises.
- (B) Instruct her to go to the local emergency room.
- (C) Tell her to complete an occurrence report.
- (D) Recommend that she apply an ice pack to the back.
9 >>The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she “hurts all over.” Which action would be most appropriate by the HH nurse? ?
- (A) Tell the HH aide to allow the client to stay in bed until the pain goes away.
- (B) Instruct the HH aide to get the client up to a chair and give her a bath.
- (C) Explain to the HH aide the client should get up and take a warm shower.
- (D) Arrange an appointment for the client to visit her healthcare provider.
10 >>The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? ?
- (A) Instruct her to assist the client with a shower.
- (B) Ask her to prepare the breakfast meal for the client.
- (C) Request her to take the client to an HCP’s appointment.
- (D) Tell her to show the client how to use a glucometer.
11 >>The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? ?
- (A) The UAP is not at risk for contracting an illness.
- (B) The UAP should wear a mask, gown, and gloves.
- (C) The UAP may skip performing postmortem care.
- (D) Ask whether the UAP is pregnant before she enters the client’s room.
12 >>The client in the operating room states, “I don’t think I will have this surgery after all.” Which intervention should the nurse implement first? ?
- (A) Have the surgeon speak with the client.
- (B) Ask the client to discuss the concerns.
- (C) Continue to prep the client for surgery.
- (D) Immediately stop the surgical procedure.
13 >>The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? ?
- (A) Check with the clients to see whether they are satisfied.
- (B) Ask the charge nurse whether the UAP is qualified.
- (C) Make rounds to see that the clients are being turned.
- (D) Watch the UAP perform all the delegated tasks.
14 >>The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement? ?
- (A) Discuss the situation with the client’s family.
- (B) Refer the client to the HH occupational therapist.
- (C) Request the HH aide to cook all the client’s meals.
- (D) Contact the community’s Meals on Wheels.
15 >>The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? ?
- (A) The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site.
- (C) The client with renal calculi who is complaining of severe flank pain and has hematuria.
- (D) The client with Addison’s disease who has bronze skin pigmentation and hypoglycemia.
16 >>The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? ?
- (A) The client who had surgery for an inguinal hernia and who is being prepared for discharge.
- (B) The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy.
- (C) The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood.
- (D) The client who has end-stage renal disease and who has had an arteriovenous fistula created.
17 >>The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? ?
- (A) The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13.
- (B) The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L.
- (C) The client diagnosed with Addison’s disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28.
- (D) The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau’s sign.
18 >>The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? ?
- (A) The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92.
- (B) The client diagnosed with pneumonia who has an oral temperature of 100.2�F.
- (C) The client diagnosed with cystitis who complains of burning on urination.
- (D) The client diagnosed with pancreatitis who complains of pain that is an 8.
19 >>The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. ?
- (A) Explain the procedure for using the patient-controlled analgesia (PCA) pump.
- (B) Check the client’s abdominal dressing for drainage.
- (C) Take and record the client’s vital signs.
- (D) Empty the client’s indwelling catheter bag at the end of the shift.
20 >>The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? ?
- (A) The nurse who has the most vacation time.
- (B) The nurse who requested to be off.
- (C) The nurse who has the least experience on the unit.
- (D) The nurse who has called in sick the previous 2 days.