Deck 5: Leadership & Management

Question 1

The registered nurse (RN) is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula.  The client makes frequent requests to use the bathroom during the night.  Which tasks can be delegated to the unlicensed assistive personnel (UAP)?  Select all that apply.

A)Assisting the client to the bathroom
B)Deciding if supplemental oxygen is necessary when the client is ambulating
C)Documenting vital signs in the electronic medical record
D)Notifying the nurse immediately if the client's respirations exceed 20/min
E)Reapplying the nasal cannula if it accidentally comes off

Answer 1

Assisting the client to the bathroom
Documenting vital signs in the electronic medical record
Notifying the nurse immediately if the client's respirations exceed 20/min
Reapplying the nasal cannula if it accidentally comes off

Question 2

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy.  Which nursing actions may the RN delegate to the LPN?  Select all that apply.

A)Assess perfusion of the stoma tissue
B)Assist the client in changing the ostomy pouch
C)Auscultate the client's bowel sounds
D)Develop plan of care to prevent skin breakdown
E)Monitor the color of ostomy drainage

Answer 2

Assist the client in changing the ostomy pouch
Auscultate the client's bowel sounds
Monitor the color of ostomy drainage

Question 3

When caring for a client with pneumonia, which nursing activities are most appropriate for the registered nurse (RN) to delegate to the licensed practical nurse (LPN) working under RN supervision?  Select all that apply.

A)Administering metered-dose inhaled medications
B)Monitoring lung sounds
C)Evaluating use of the incentive spirometer
D)Nasotracheal suctioning to collect a sputum specimen
E)Teaching the importance of fluid intake

Answer 3

Administering metered-dose inhaled medications
Monitoring lung sounds
Nasotracheal suctioning to collect a sputum specimen

Question 4

A client is hospitalized for a broken leg.  The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago.  Which staff members can safely care for this client?  Select all that apply.

A)Nurse floated from another medical-surgical floor
B)Nurse who is 24 weeks pregnant
C)Nurse with erythematous rash and honey-color crusts on the hand
D)Unlicensed assistive personnel who just received the yearly injectable flu vaccination
E)Unlicensed assistive personnel with a cold

Question 5

The nurse practicing on a medical surgical unit cares for a client with type I diabetes mellitus.  Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP)?

A)Assess the client for signs and symptoms of hypoglycemia
B)Check the blood glucose before meals and report it to the primary nurse
C)Teach the client to cut toenails straight across and file with rounded curves of the toes
D)Update the care plan to include client's preference for nighttime diabetic snack

Question 6

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation.  The "right direction and communication" related to the task is one of those rights.  Which statement best meets that standard?

A)"I need for you to take vital signs on all clients in rooms 1-10 this morning."
B)"Mr. Wu's blood pressure has been low.  Please take his vital signs first and let me know if his systolic blood pressure is <100."
C)"Mrs. Jones fell out of bed during the night.  Be sure you keep a close eye on her this shift."
D)"Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

Question 7

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit.  A client who is about to be discharged home with tube feedings needs care.  Which responsibilities should the RN delegate to the LPN?  Select all that apply.

A)Cleaning the skin surrounding the gastrostomy tube stoma
B)Crushing and administering metoprolol through the gastrostomy tube
C)Programming the feeding pump to administer a prescribed bolus feeding
D)Teaching the client about home enteral feeding and gastrostomy tube care
E)Weighing the client using the bed scale

Question 8

The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments.  Which assignment made by the RN is most appropriate?

A)A licensed practical nurse (LPN) assigned to a client receiving blood transfusions
B)A student nurse assigned to a client who requires frequent intravenous pain medication
C)An LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today
D)An RN assigned to a client 1 day postoperative repair of a compound fracture

Question 9

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis.  Which of the following actions can be delegated to unlicensed assistive personnel?  Select all that apply.

A)Administer artificial tears if the client reports eye dryness
B)Assist the client to bathe and change the bed linens to maintain client comfort
C)Lower the room temperature and provide cool cloths on request
D)Reinforce to the client that fever is expected with thyrotoxicosis
E)Return a call to the client's family telling them the client's condition is unchanged

Question 10

The registered nurse (RN) and practical nurse (PN) are caring for a client who was admitted to the medical unit last night with a moderate asthma exacerbation and an upper respiratory infection.  Which tasks are appropriate for the RN to delegate to the PN?  Select all that apply.

A)Administering albuterol metered-dose inhaler medication
B)Auscultating lung sounds to determine the response to a bronchodilator
C)Checking oxygen saturation with the pulse oximeter
D)Measuring morning peak expiratory flow with the client's peak flow meter
E)Teaching the client about a newly prescribed inhaled corticosteroid

Question 11

Which of these tasks are appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?  Select all that apply.

A)Assign lunch times to the other UAP on the unit
B)Assist a client with a new ostomy with bathing and changing pouches
C)Collect vital signs on a client 4 hours after laparoscopic appendectomy
D)Pick up an intravenous antibiotic from the pharmacy
E)Record intake and output for a client with metabolic alkalosis

Question 12

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone.  Which tasks can the registered nurse (RN) delegate to the experienced unlicensed assistive personnel (UAP)?  Select all that apply.

A)Assisting the client in completing a health history form
B)Collecting a urine specimen for culture and sensitivity
C)Instructing the client to strain urine when voiding
D)Measuring and documenting urine output
E)Monitoring the color and characteristics of urine output

Question 13

The charge nurse on a medical-surgical step-down unit is responsible for making assignments.  Which client ismost appropriate to assign to a new graduate nurse who is still in orientation?

A)65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse
B)66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision
C)75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis
D)78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

Question 14

The registered nurse (RN) is discussing care of shared clients with the licensed practical nurse.  Which of the following clients require intervention by the RN?  Select all that apply.

A)A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mm Hg and pulse 110/min
B)A client receiving oral metoprolol whose heart rate has decreased to 60/min after administration
C)A client whose blood pressure decreased from 130/80 mm Hg to 110/70 mm Hg following administration of 1 mg hydromorphone IV
D)A client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered
E)A client whose pulse increased from 70/min to 100/min after albuterol administration

Question 15

Which tasks can the registered nurse safely delegate to unlicensed assistive personnel?  Select all that apply.

A)Ambulate an oxygen-dependent client to the bathroom
B)Assist client with dentures to perform oral suctioning after the client's meal
C)Document pulse oximetry of a client with chronic obstructive pulmonary disease
D)Instruct a client with pneumonia on use of the incentive spirometer
E)Turn and reposition a client with pneumonia

Question 16

The registered nurse is caring for multiple clients on a medical-surgical unit and has finished the morning assessment.  Which task is appropriate for the nurse to delegate to unlicensed assistive personnel?

A)Apply a collagenase dressing to a client's pressure ulcer for wound debridement
B)Assist a client 1 day postoperative hip fracture repair to the bathroom
C)Feed a client through a gastrostomy tube after elevating the head of the bed
D)Offer orange juice to a client if the blood glucose level is <70 mg/dL (<3.9 mmol/L)

Question 17

The charge nurse on the telemetry unit is making client assignments.  Which client is appropriate to assign to the licensed practical nurse (LPN)?

A)Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void
B)Client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections
C)Client who has just been admitted to the telemetry unit from the emergency department with a rule-out myocardial infarction
D)Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg;  currently is 110/62 mm Hg

Question 18

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse.  Which assignment is most appropriate for a new graduate nurse?

A)A 36-year-old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning
B)A 56-year-old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery
C)A 68-year-old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning
D)An 80-year-old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

Question 19

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)?

A)A client experiencing Addisonian crisis with a prescription for hydrocortisone IV
B)A client with Cushing syndrome who needs intermittent urinary catheterization
C)A client with diabetic ketoacidosis on insulin intravenous (IV) infusion
D)A client with thyrotoxicosis and new-onset atrial fibrillation

Question 20

Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)?

A)Assisting a client in ambulating to the bathroom for the first time following surgery
B)Explaining why using the incentive spirometer is important to a client with postoperative pneumonia
C)Feeding a client with dementia who has a blood sugar of 70 mg/dL (3.9 mmol/L)
D)Taking vital signs every 15 minutes on a client who was just transferred from the post- anesthesia recovery unit

Question 21

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel?  Select all that apply.

A)Assist the registered nurse with ambulating a client 1-day post chest tube placement
B)Measure wound drainage from a bulb drain and document it on the output flow sheet
C)Monitor for redness and swelling at the IV insertion site and report back to the nurse
D)Return an unused unit of packed red blood cells to the blood bank
E)Take family members to the waiting room after the client goes into surgery

Question 22

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse?  Select all that apply.

A)Administer heparin continuous infusion to a client with a venous thromboembolism
B)Auscultate bowel sounds 2 days after repair of an inguinal hernia
C)Discuss concerns about last shift's care with an irate family member
D)Monitor flow rate and drainage in a client receiving bladder irrigation
E)Teach Kegel exercises after a client has a catheter removed

Question 23

The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath.  What should the charge nurse do first?

A)Activate a rapid response team
B)Ask the UAP to take vital signs and report back
C)Notify the client's assigned licensed practical nurse (LPN) to assess the client
D)Personally go and auscultate the client's lungs

Question 24

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse, and unlicensed assistive personnel (UAP).  Which tasks can the charge nurse appropriately delegate to UAP?  Select all that apply.

A)Apply protective skin ointment after perineal cleansing
B)Determine if a client has adequate relief after administration of an analgesic
C)Document daily weight for a client with congestive heart failure
D)Feed a client who had a stroke 24 hours after admission
E)Perform passive range-of-motion exercises for a client on a ventilator

Question 25

The registered nurse (RN) is working with unlicensed assistive personnel (UAP).  Which task can the RN safely delegate to the UAP?

A)Assisting a 2-day postoperative hip arthroplasty client with morning care
B)Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter
C)Initial change of colostomy bag for a client who is 1-day postoperative colostomy
D)Refilling the empty enteral feeding container with tube feeding

Question 26

The nurse is delegating client care tasks to a licensed practical nurse (LPN) and unlicensed assistive personnel.  Which of the following assignments are most appropriate to assign to the LPN?  Select all that apply.

A)Administer a client's daily dose of subcutaneous insulin glargine
B)Administer a scheduled oral analgesic to a 2 days postoperative client
C)Complete an admission nursing interview for a client admitted for elective hysterectomy
D)Reinforce teaching on self-administration of insulin to a client with diabetes mellitus
E)Tally the shift's intake and outputs for the entire unit

Question 27

A nurse delegates a task to the unlicensed assistive personnel (UAP).  The UAP states, "I can't do that."  Which is the best initial response for the nurse to make?

A)Ask the UAP the reason for the response
B)Do the task, but discuss the UAP's response with the manager
C)Ignore the UAP's initial response and repeat the delegation request
D)Remind the UAP of the importance of teamwork

Question 28

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest.  The nurse is not familiar with this client population and does not want to go.  What is the best response by the psychiatric nurse?

A)Clarify the skills/knowledge that the nurse is able/unable to perform
B)Read the policy and procedure book for the unit before providing care
C)Refuse to go due to concerns about client safety
D)Tell the supervisor to send someone else instead

Question 29

The registered nurse (RN) is caring for a postoperative client with a Hemovac drain.  Which task is inappropriate for the RN to ask the experienced unlicensed assistive personnel (UAP) to perform?

A)"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client."
B)"Please measure the Hemovac drainage at 2:00 PM and let me know how much there was."
C)"Please record the amount of the Hemovac drainage on the intake and output record at the end of the shift."
D)"Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught."

Question 30

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP).  Which of these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP?  Select all that apply.

A)"Elevate the right leg on two pillows."
B)"Measure client for compression stockings."
C)"Please let me know what the urine looks like."
D)"Tell me what the client eats at lunch."
E)"Verify wrist restraints are on correctly."

Question 31

Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit?

A)Client who just returned to the unit after coronary angioplasty and placement of a stent
B)Client with atrial fibrillation scheduled for electrical cardioversion this afternoon
C)Client with heart block scheduled for pacemaker placement this afternoon
D)Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

Question 32

The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine.  What action should the nurse take first?

A)Have the unlicensed assistive personnel recheck the client's blood pressure
B)Immediately notify the health care provider
C)Obtain the client's PRN labetalol from the medication dispensing machine
D)Recheck the client's blood pressure with a manual cuff

Question 33

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift.  Which client is most appropriate for the charge nurse to assign to the L&D nurse?

A)Client with an occluded arteriovenous fistula receiving IV heparin infusion
B)Client with cirrhosis and ascites who requires bedside paracentesis
C)Client with diabetes who is one day postoperative below-the-knee amputation
D)Client with pyelonephritis who is febrile and receiving IV antibiotics

Question 34

The nurse is assisting the health care provider with a lumbar puncture in the client's room.  The unit secretary calls over the room intercom and tells the nurse that the laboratory is on the phone with a critical value report for one of the nurse's other clients.  What action should the nurse take?

A)Ask the unit secretary to write down a message from the laboratory personnel
B)Instruct the unit secretary to have the charge nurse receive the report
C)Leave the room to talk to the laboratory on the phone and then return immediately
D)Tell the unit secretary to have laboratory personnel send a written result

Question 35

The registered nurse is working with a licensed practical nurse and unlicensed assistive personnel.  A client has just returned to the cardiac unit after a percutaneous coronary intervention.  Which actions are most appropriate for the registered nurse to assign to the licensed practical nurse?  Select all that apply.

A)Administer oral pain medication for the client's chronic lower back pain
B)Assist the client with the use of a urinal post-procedure
C)Monitor for bleeding at the catheter insertion site every 15 minutes
D)Perform the initial post-procedure vital sign measurements
E)Review the ECG monitor for dysrhythmias

Question 36

The night charge nurse is making assignments for the next shift.  Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit?

A)Client newly admitted for an evolving ischemic stroke
B)Client newly diagnosed with diabetes mellitus who needs insulin administration teaching
C)Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy
D)Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

Question 37

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol.  Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety?  Select all that apply.

A)Orient the client to the bedside unit and explain the call bell system on admission
B)Place the bedside commode as close to the bed as possible
C)Remind the client to change position slowly
D)Report observations of changes in client's condition immediately
E)Report whether client is using correct gait and balance while ambulating with walker

Question 38

The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP).  The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client?

A)A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today
B)A 6-month-old who had diaphragmatic hernia repair 5 days ago
C)A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm³
D)A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing

Question 39

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions.  The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)?  Select all that apply.

A)Alert the x-ray department about maintaining airborne isolation precautions
B)Explain to the client why the client must wear a mask during transport to another department
C)Post signs for airborne isolation precautions on the client's door and stock necessary equipment
D)Remind visitors to wear a respirator mask and keep the door closed while in the client's room
E)Talk with the family about the reasons for airborne isolation precautions in the client

Question 40

The charge nurse on a medical unit makes assignments for the nursing team composed of a registered nurse (RN), 2 licensed practical nurses (LPNs), and a student nurse (SN).  Which assignment is the most appropriate?

A)LPN assigned to a client with a gastrointestinal bleed and hypotension who is receiving blood and requires vital sign monitoring every hour
B)LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain
C)RN assigned to a client with a change in mental status who is being transferred to the intensive care unit
D)SN assigned to a client with multiple sclerosis and dysphagia who requires multiple oral and IV medications

Question 41

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel (UAP).  Which of the following tasks are appropriate for the nurse to assign to UAP?  Select all that apply.

A)Emptying a urinary drainage bag and recording output volume
B)Emptying and verifying the patency of an accordion drain
C)Escorting a disgruntled family member off the unit
D)Providing perineal care around an indwelling urinary catheter
E)Reapplying bilateral sequential compression devices

Question 42

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery.  Which pain management-related tasks should the RN delegate to the LPN?  Select all that apply.

A)Administering oral pain medication
B)Assessing characteristics of pain
C)Measuring vital signs before and after analgesic administration
D)Monitoring pain level using a numeric scale
E)Providing discharge teaching about pain management

Question 43

The postpartum nurse receives report on 4 mother-baby couplets.  Which tasks can be delegated to unlicensed assistive personnel?  Select all that apply.

A)Assisting the mother with morning hygiene
B)Demonstrating neonate bathing technique
C)Documenting intake and output on the mother
D)Evaluating caregiver interaction with the neonate
E)Obtaining an axillary temperature on the neonate
F)Swaddling the neonate after diaper changes

Question 44

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client?

A)Client with diet-controlled gestational diabetes
B)Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg
C)Client with premature rupture of membranes 6 hours ago at 37 weeks gestation
D)Client with spontaneous rupture of membranes with greenish amniotic fluid

Question 45

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit?

A)Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist
B)Client 3-days post knee replacement surgery awaiting discharge
C)Client who is scheduled for an above-the-knee amputation today
D)Client with a long leg cast applied yesterday morning to treat a fractured ankle

Question 46

The nurse is making assignments for the next shift.  Which client should the nurse assign to the new nurse coming out of orientation?

A)Client diagnosed with chronic anemia receiving iron via IV route
B)Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L)
C)Client undergoing ultrafiltration for congestive heart failure
D)Client with a prescription for routine hemodialysis who has chronic renal failure

Question 47

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards?  Select all that apply.

A)Assist with active and passive range of motion (ROM) exercises
B)Change bed linens while logrolling the client from side to side
C)Check the color and temperature of the affected extremity
D)Remind the client to use the incentive spirometer
E)Reapply pneumatic compression device after bathing the client

Question 48

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit.  Which tasks may be delegated to experienced unlicensed assistive personnel?  Select all that apply.

A)Assisting clients with bathing and hair care
B)Evaluating safety hazards in clients' rooms
C)Monitoring clients for behavioral changes
D)Placing bed alarms at night for clients at risk for wandering
E)Reporting swallowing difficulties of a client during mealtime

Question 49

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit?

A)Client experiencing fever and pain with mastitis
B)Client preparing for discharge after cesarean birth
C)Client showing disinterest in caring for the newborn
D)Client with hysterectomy after postpartum hemorrhage

Question 50

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer.  No family members were present at the time of death.  What interventions can be delegated to experienced unlicensed assistive personnel?  Select all that apply.

A)Notifying the family of the client's death
B)Placing dentures in the client's mouth
C)Positioning a pillow beneath the client's head
D)Transporting the client to the morgue
E)Washing the client's body

Question 51

A pediatric nurse is floated to an adult medical surgical unit.  Which client assignment would be most appropriate for the pediatric nurse?

A)Client with alcohol withdrawal who needs IV lorazepam every 2 hours
B)Client with emphysema and an oxygen saturation of 89% on room air
C)Client with sickle cell crisis requiring IV morphine every 2 hours
D)Client with type 2 diabetes mellitus who needs discharge teaching

Question 52

The nurse is preparing to administer a unit of packed red blood cells to a client whose hemoglobin is 7 g/dL (70 g/L).  What tasks can the nurse delegate to unlicensed assistive personnel?  Select all that apply.

A)Assist with checking identification of the client and the blood product
B)Measure vital signs at the end of the transfusion
C)Measure vital signs prior to starting the transfusion
D)Measure vital signs within the first 10 minutes of starting the transfusion
E)Pick up blood from the blood bank

Question 53

A float nurse from labor and delivery is assigned to the cardiac care unit.  Which client is most appropriate for the charge nurse to assign to the float nurse?

A)Client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea
B)Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO
C)Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min
D)Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

Question 54

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention.  Which tasks would be appropriate to delegate to the unlicensed assistive personnel?  Select all that apply.

A)Document output from the urinary collection bag
B)Hold adipose tissue out of the way during catheter insertion
C)Monitor color of the urine after the nurse has assessed it
D)Reinforce education about the purpose of the urinary catheter
E)Secure the catheter to the client's thigh with an anchor

Question 55

The registered nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP).  Which tasks are most appropriate to assign to the LPN?  Select all that apply.

A)Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10
B)Assessing fluid volume status of a client with heart failure who is scheduled for discharge
C)Assisting with bathing, feeding, and dressing a client with multiple sclerosis
D)Performing wound care and sterile dressing change for a client with a stasis ulcer
E)Providing incontinence care and linen change for a client with diarrhea

Question 56

The registered nurse, licensed practical nurse (LPN), and unlicensed assistive personnel are assigned a client who is being transferred from the post-anesthesia care unit (PACU).  Which tasks are the most appropriate to delegate to the LPN?  Select all that apply.

A)Assess the client on admission
B)Measure vital signs and pulse oximetry
C)Monitor pain level and administer pain medications
D)Receive verbal report from the PACU nurse
E)Reposition client every 2 hours
F)Titrate oxygen based on unit protocols

Question 57

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit.  What client care tasks can the nurse safely delegate to the unlicensed assistive personnel?  Select all that apply.

A)Applying moisturizing solution to the oral mucosa and lips
B)Cleaning the area around tracheostomy stoma with normal saline
C)Educating the family to maintain the head of the bed at least 30 degrees
D)Obtaining and documenting respiratory rate and pulse oximetry readings
E)Performing passive and active range-of-motion exercises

Question 58

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients.  Which tasks can the RN delegate to the licensed practical nurse?  Select all that apply.

A)Administering enoxaparin subcutaneously to a client in skeletal traction
B)Applying sequential compression devices to a client with limited mobility
C)Evaluating partial thromboplastin time in a client receiving heparin
D)Measuring a client with chronic heart failure for compression stockings
E)Teaching a client with a new prescription for warfarin about bleeding precautions

Question 59

The registered nurse (RN) prepares to give out client care assignments.  Which client is appropriate for the RN to assign to the licensed practical nurse (LPN)?

A)Client admitted 3 hours ago with suspected acute pancreatitis
B)Client who had a total right hip replacement 2 days ago
C)Client who had a total thyroidectomy 2 hours ago
D)Client with alcohol withdrawal syndrome

Question 60

The nurse is caring for a client in soft wrist restraints.  Which tasks can the nurse safely delegate to the unlicensed assistive personnel?  Select all that apply.

A)Assist the client with using a bedpan
B)Check pulses and sensation of extremities
C)Observe skin for signs of impairment
D)Perform range-of-motion exercises
E)Turn and reposition the client in bed

Question 61

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body.  The visitor asks the nurse to take a blood pressure reading.  What is the most appropriate response by the nurse?

A)Encourage the visitor to lie down to see if symptoms change
B)Initiate protocol to assist the visitor to the emergency department
C)Proceed to take the visitor's blood pressure
D)Suggest that the visitor call the health care provider

Question 62

The nurse is participating in staff training about protecting clients' privacy and confidentiality.  Which of the following incidents does the nurse recognize as a violation of client confidentiality?  Select all that apply.

A)A visitor talking in the waiting room states that the client has alcoholism
B)The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
C)The nursing assistant tells a client that the hospital roommate went for a gallbladder test
D)The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
E)Two LPNs are discussing a possible cure for AIDS on a crowded elevator

Question 63

Which statements related to ethical nursing practices are correct?  Select all that apply.

A)Accountability is documenting that the nurse administered the wrong medication
B)Autonomy is informing the client of the decision the family made for the client
C)Confidentiality is respecting a client's request to keep suicidal ideation a secret
D)Justice is providing the same cardiac care to a homeless person as a businessperson
E)Nonmaleficence is reporting abuse for a client with Alzheimer disease

Question 64

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen.  How should the nurse respond?

A)Ask about liver disease and give acetaminophen from the nurse's personal supply
B)Assess the employee's blood pressure
C)Check for allergies to drugs before giving acetaminophen from hospital stock
D)Refer employee to the employee health provider

Question 65

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive.  Resuscitation is initiated and then continued by the rapid response team.  The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart.  Which action is correct?

A)Stop all resuscitation activity immediately
B)Continue resuscitation until DNR status is verified with health care provider
C)If client shows any signs of life, follow advanced cardiovascular support protocol until stable
D)Once resuscitation has begun, complete it regardless of client code status

Question 66

Which are correct understandings of applying nursing ethical principles?  Select all that apply.

A)Autonomy is requiring the client to have an advance directive
B)Beneficence is withholding prognosis from a client due to family wishes
C)Fidelity is administering medication as prescribed to the client
D)Justice is telling the client the truth that the biopsy is positive
E)Nonmaleficence is refusing to give report to a nurse who is impaired

Question 67

The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week.  Which client assignment is most appropriate?

A)3-year-old with a temperature of 102.4 F (39.1 C) who had a seizure at home 30 minutes ago and is very irritable
B)8-year-old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale
C)32-year-old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best
D)72-year-old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

Question 68

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood.  The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations?  Select all that apply.

A)The nurse accepts money from the victim
B)The nurse does not accompany the victim on the ambulance
C)The nurse does not apply direct pressure to the artery
D)The nurse knows the victim from college
E)The victim dies after reaching the hospital

Question 69

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff.  A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?"  Which response by the nurse is appropriate?

A)"I don't know because I am off duty right now."
B)"Let's step away from the crowd to discuss it."
C)"Mrs. Jones was fine when I last checked on her during rounds."
D)"You will have to talk with the nurse caring for her while I am on break."

Question 70

The charge nurse is making assignments for the oncoming shift.  Which client assignments should be avoided by the nurse who is pregnant?

A)2-year-old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy
B)5-year-old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus
C)9-year-old client with parvovirus B-19 infection admitted for observation after a febrile seizure
D)14-year-old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

Question 71

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress.  The client's sister is the legal medical power of attorney.  Both the client's spouse and sister are present.  Which action by the nurse is appropriate at this time?

A)Ask the spouse about the client's wishes
B)Get directions about care from the client's sister
C)Prepare for emergency intubation
D)Request that the sister provide a living will

Question 72

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting?

A)A 2-month-old who rolled off the changing table and is now lethargic
B)A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth
C)A 3-year-old with forehead bruises that the mother says come from running into a table
D)A 4-year-old who pulled boiling water off the stove and has splattered burns on the arms

Question 73

Which of the following are violations of protected client health information?  Select all that apply.

A)Client overhears the nurse give report on the client's roommate through the room curtain.
B)Nurse calls a client by the first and last names in the public waiting room.
C)Nurse gives a pregnancy result to the client's partner without the client's permission.
D)Nurse tells the transporting tech that the client has breast cancer.
E)Unlicensed assistive personnel tells a discharged client, "You take care now!"

Question 74

Which emergency department clients cannot be allowed to sign out against medical advice?  Select all that apply.

A)Client in sickle cell crisis receiving oxygen via face mask
B)Client who drank a 1 L bottle of vodka 2 hours ago
C)Client who hears voice commands to kill a coworker
D)Client with mania who has not eaten in 5 days
E)Client with ST elevation on ECG monitoring

Question 75

A male client has terminal metastatic disease.  He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts.  What should the nurse's response be?

A)Apply oxygen at 2 L by nasal cannula
B)Ask the client if he wants to change his mind
C)Ask the spouse what she wants done
D)Determine who has medical power of attorney

Question 76

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care?  Select all that apply.

A)Client diagnosed with lumbar spinal cord compression has paraplegia
B)Client's Glasgow Coma Scale (GCS) score is 3
C)Client is refusing a life-saving treatment due to religious beliefs
D)Client with intracerebral hemorrhage has aphasia
E)Oriented client has cancer and is on a ventilator

Question 77

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation.  The nurse walks into the room and finds that the client is not breathing.  What should the nurse do first?

A)Activate the code system
B)Call the health care provider (HCP) stat
C)Check the apical pulse
D)Check the blood pressure

Question 78

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube."  What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making?  Select all that apply.

A)Document this communication in the electronic health record
B)Encourage the client to discuss this decision with the health care proxy
C)Facilitate completion of an advance directive that reflects the client's decision
D)Obtain a signed informed consent from the client
E)Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order

Question 79

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan.  When assessing the client's advance care planning needs, which topics should the nurse discuss?  Select all that apply.

A)Financial power of attorney
B)Health care proxy
C)Life insurance beneficiary
D)Living will
E)Safe deposit box

Question 80

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?

A)5-year-old client with meningitis whose parent refuses antibiotics
B)Client who tried to commit suicide by taking a handful of acetaminophen an hour ago
C)Client with a urinary tract infection who is disoriented to time and place
D)Client with coffee-ground emesis from chronic use of high-dose aspirin