DELEGATION AND PRIORITIZING 1. A nurse from medical-surgical unit is asked to work on the orthopedic unit.

The medicalsurgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse? a) a client with a cast for a fractured femur and who has numbness and discoloration of the toes b) a client with balanced skeletal traction and who needs assistance with morning care c) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F d) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring 1) D - a nurse from medical-surgical unit floated to the orthopedic unit should be given clients with stable condition, and those whose care are similar to her training and experience. A client who is 2-day postop is more likely to be on stable condition. And the medical-surgical unit nurse is competent in monitoring blood glucose. 2. The nurse plans care for a client undergoing a colposcopy. Which of the following actions should the nurse take first? a) discuss the client's fear regarding potential cervical cancer b) assist with silver nitrate application to the cervix to control bleeding c) provide instructions regarding douching and sexual relations d) administer pain medication 2) B - the priority nursing action when caring for a client who will undergo colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix. 3. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first? a) a client with diabetes being discharged today b) a client with tracheostomy and copious secretions c) a client scheduled for physical therapy this morning d) a client with a pressure ulcer that needs dressing change 3) B - a patient with problem of the airway should be given highest priority. ABC is a priority. 4. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first? a) call for help to get the client back in bed b) establish whether the client is responsive c) assist the client back to bed d) ask the client what happened 4) B - assessing for responsiveness is the first nursing action when performing CPR 5. A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is due to: a) role modeling behaviors of the preceptor b) the philosophy of the new nurse's school of nursing c) the orientation provided to the new nurse d) lack of trust in the team members 5) D- lack of trust is the most common reason for reluctance in delegating tasks among members of the team.

6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do first? a) decontaminate the client's clothing b) decontaminate an open wound on the client's thigh c) decontaminate the examination room the client is placed in d) save the client's vomitus for analysis by the radiation safety staff 6) B - decontaminating an open wound is the first priority when caring for a client after a radiologic incident. This minimizes absorption of radiation in the client's body. 7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first? a) respiratory status b) level of consciousness c) level of pain d) reflexes and movement of extremities 7) A - assessing respiratory status is the first priority when caring for a client in the post-anensthesia care unit. ABC is a priority. 8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet? a) fiber b) broccoli c) yogurt d) simple carbohydrates 8) B - broccoli is gas forming. This should be avoided in clients experiencing flatulence. 9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent? a) pain b) wound infection c) depression d) thrombophlebitis 9) B - wound infection is the most common complication among obese clients who had undergone surgery. This is due to poor blood supply in the adipose tissues. Therefore, there is decreased oxygen supply and diminished supply of protective cells in the areas. 10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first? a) administer pain medication b) administer IV fluids c) administer dopamine d) administer oxygen per nasal cannula

10) D - promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest priority by the nurse for a client with dyspnea, chest pain, and syncope. 11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first? a) sit the client in a geriatric chair with an activity b) apply a vest restraint when the client is in a chair c) apply bilateral wrist restraints when the client is in bed d) have a staff member sit with the client at all times 11) A promotion of safety and providing diversional activities are priority nursing care for confused elderly clients. Application of restraints should be the last resort. Having a staff member sit with the client at all times is not necessary, unless the client is at risk to injury. 12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first? a) perform venipuncture and start an IV line b) administer oxygen via nasal cannula c) administer morphine sulfate intravenously d) start lidocaine (xylocaine) infusion 12) B - administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation. 13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first? a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath b) a 16 year old male with ecchymosis, pain, and swelling of the right arm c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain d) an 8 year old child who is crying hysterically and reports abdominal pain 13) A - the client with problem of the airway and who has unstable condition should be given highest priority. Priority ABC. 14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is: a) assess the child's airway and breathing b) call 911 and request an ambulance c) administer subcutaneous epinephrine d) remove the stinger from the foot 14) A - the situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC. 15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is: a) tell the mother to position the child lying down on her side

b) tell the mother to dial 911 and request an ambulance c) have the mother give the child a glass of milk d) instruct the mother on how to administer syrup of ipecac 15) D - acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of ipecac is appropriate management in case of acetaminophen overdose or poisoning. 16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first? a) call for a social worker to meet with the family b) check the child's blood pressure, then pulse, respiration, and temperature c) administer pain medication d) speak with the parents about how the fracture occurred 16) D - in case of injury especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse. 17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first? a) a client scheduled for cardiac ultrasound this morning b) a client with syncope being discharged today c) a client with chronic bronchitis on nasal oxygen d) a client with a diabetic foot ulcer that needs a dressing change 17) C - a client with problem of the airway should be attended first. ABC is a priority. 18. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first? a) determine level of consciousness b) push the call button for help c) turn the client face up to assess d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician 18) A - assessing level of consciousness is the first action when dealing with a situation where the client might have had a fall or when preparing to do CPR (cardio-pulmonary resuscitation). 19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best? a) ask the other nurse if she needs any help b) assess the client, and let the other nurse know what should be done c) ask the client if he is satisfied with his care d) contact the nursing supervisor to address the situation 19) D - the RN should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team. 20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vascular disease. The caregiver learns that which immunization is a priority for the client? a) hepatitis A vaccine b) lyme disease vaccine c) hepatitis B vaccine

d) pneumococccal vaccine 20) D pneumococcal vaccine is a priority immunization for the elderly, especially those with chronic illness. It is administered every 5 years. 21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant: a) advances the catheter 4 inches into the anal canal b) hangs the enema bag 12 to 18 inches above the anus c) lubricates 4 to 5 inches of the catheter tip d) positions the client on the right side with head slightly elevated 21) D - the appropriate position of the client during enema administration is left lateral position to facilitate flow of solution by gravity. Therefore, the action of the CNA in choices no. 4 needs to be corrected. 22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse regarding care of a client with crutches is most appropriate? a) the client needs to ambulate with crutches and a two-point gait b) ambulate the client without weight bearing every 4 hours the length of the hall and back c) ask the client if she understands how to use a two-point gait, if not, please explain it to the client d) make sure the client does not bend the elbows when using the crutches 22) B - when delegating task, the nurse should provide complete, concrete and specific directions. 23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first? a) a client who received chemotherapy yesterday and is reporting nausea and vomiting b) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urine c) a client with schizophrenia who says that the police has surrounded the house d) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during the night 23) D - the situation indicates development of pulmonary edema in the client with chronic heart disease. This serious complication is a priority. 24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first? a) a 3-year old child who cannot find her parents and is reporting a headache b) a 48-year old male who has burns on both hands and reports severe pain c) an 18-year old male who jumped from a second story window and is reporting severe arm pain d) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing 24) D - burns on the face and neck involves obstruction of airway due to smoke inhalation. Airway is a priority. 25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not remembering what happened to the night before. The first

action the nurse should take is: a) obtain a rape kit b) ask the client if she thinks she was raped c) place the client in an examining room and leave her while she puts on a gown d) provide a quiet, private area to use for initial assessment of the client 25) D - this situation indicates possible rape of the client. Providing psychosocial support and ensuring privacy for initial assessment of the client is most appropriate initial action. 26. A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP). Which of the following are essential to effective delegation? a) give the UAP written instructions for assignments b) make frequent walking rounds to assess clients c) delegate tasks based on the experience of the UAP d) take frequent mini-reports from the UAP e) have the UAP repeat instructions f) explain unexpected outcomes of delegated tasks to the UAP 26) A, B, C, D, E, F - all of these aspects are essential fro effective delegation. 27. A nurse is teaching a class regarding lead poisoning in children to student nurses. The nursing students learn to target which priority group of children for screening? a) those with sickle cell anemia b) those who live in homes built in the 1960's c) those who live in low-income families d) adolescents living in the inner city 27) C - lead poisoning is common in old houses (built in 1950's), and in places with unsanitary conditions including soil, dust, vehicles using leaded gas. These factors are common among lowincome families. 28. A nurse is attending an In-service training class on delegation. The nurse learns that proper delegation can involve which of the following? Select all that apply a) giving authority b) delegating nursing process c) delegating tasks d) delegating accountability e) delegating responsibility f) giving orders 28) A, C, and E- proper delegation involves giving authority, delegating tasks, and delegating responsibility. Nursing process, accountability and giving orders are to be done by the RN, and not to be delegated. 29. When developing the plan of care for a client with suicidal ideation, which of the following would the nurse anticipate as the priority? a)Self-esteem b)Sleep c)Hygiene d)Safety 29) D - for the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep and hygiene are common

areas that require intervention for a client with suicidal ideation, ensuring the client s safety is the most immediate and serious concern. 30. A client in early labor is receiving oxytocin. When observing late decelerations in the fetal heart rate, the nurse should first: a) Administer oxygen b) Place her on her left side c) Check the blood pressure d) Discontinue the oxytocin infusion 30) D - the infusion should be stopped because it is placing the fetus in danger. 31. A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a) a client complaining of muscle aches, a headache, and malaise b) a client who twisted her ankle when she fell while rollerblading c) a client with a minor laceration on the index finger sustained while cutting an eggplant d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce 31) D - In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority 32. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? a) a client requiring colostomy irrigation b) a client receiving continuous tube feedings c) a client who requires urine specimen collections d) a client with difficulty swallowing foods and fluids 32) C - The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. 33. The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a) the client who requires a bed bath b) an older client requiring frequent ambulation c) a client who requires a 24-hour urine collection

d) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours 33) D - When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. 34. The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? a) A client who is ambulatory b) a client scheduled for physical therapy at 1PM c) a client with a fever who is diaphoretic and restless d) a postoperative client who has just received pain and medication 34) C The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client s needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. 35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a) a client scheduled for a chest x-ray b) a client requiring daily dressing changes c) a postoperative client preparing for discharge d) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift 35) D - Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options A, B, and C have needs that would be identified as intermediate priorities. 36. The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following? a) finish the bed bath and then administer the pain medication to the other client b) ask the nursing assistant to find out when the last pain medication was given to the client c) ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete d) cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client 36) D - The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options A and C delay the administration of medication to the client in pain. Option B is not a responsibility of the nursing assistant. 37. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to preform the Allen's Test on the client. Arrange in order of priority the steps for performing Allen's test. (Letter A is the first step and letter F is the last step. a) document the findings

b) explain the procedure to the client c) release pressure from the ulnar artery d) apply pressure over the ulnar and radial arteries e) ask the client to open and close the hand repeatedly f) assess the color of the extremity distal to the pressure point 37) F, A, D, B, C, E - The Allen s test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client s ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings. 38. A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. Arrange the actions that the nurse would take in order of priority (Letter A is the first action and letter F is the last action). a) administer oxygen b) contact the physician c) document the occurrence d) take the client's vital signs e) clamp the intravenous catheter f) position the client in left trendelenburg position 38) D, C, F, E, A, B - If air embolism is suspected, the nurse would first clamp the intravenous catheter to prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). The nurse would notify the physician and administer oxygen as prescribed. The nurse would monitor the client closely and take the client s vital signs. Finally, the nurse documents the occurrence. 39. A client has 1L bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45PM finds that the client is complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 ml remaining. The nurse should take which of the following action first? a) call the physician b) slow the IV infusion c) sit the client up in bed d) remove the IV catheter 39) B - The client s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client s breathing, if necessary. The nurse also notifies the physician immediately. The IV catheter is not removed; it may be needed once the complication has been resolved.

40. The nurse determines that he client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? a) remove the IV line b) run normal saline at a keep vein open rate c) run a solution of 5% dextrose in water d) obtain a culture of the tip of the catheter device removed from the client 40) B - If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep vein open rate pending further physician orders. This maintains a patent IV access line and aids in maintaining the client s intravascular volume. The nurse would not discontinue the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump. 41. A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.) a) hang the bag of blood b) obtain the unit of blood from the bank c) ensure that an informed consent has been signed d) verify the physician's order for the blood transfusion e) insert an 18 or 19-gauge IV catheter into the client f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity. 41) F, D, B, A, C, E - The nurse would first verify the physician s order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product against the client s identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion. 42. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following? a) open the airway b) give the client oxygen c) start chest compressions d) ventilate with a mouth-to-mask device

42) A - The next nursing action would be to open the airway. Ventilation cannot be initiated unless the airway is opened. Chest compressions are started after opening the airway and initiating ventilation. Oxygen may be helpful at some point, but the airway is opened first. 43. A nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange in order of priority the steps of adult CPR. (Letter A is the first step and letter F is the last step.) a) initiate breathing b) open the client's airway c) determine breathlessness d) perform chest compressions e) check for a pulse at the carotid artery f) determine unconsciousness by shaking the client and asking "Are you OK?" 43) D, B, C, F, E, A - The sequence for basic CPR for health care providers is as follows. After determining unconsciousness, the airway is opened and breathlessness is determined. Next, the health care provider delivers effective breaths that produce a visible rise in the chest, followed by assessing the carotid artery for presence of a pulse. In the absence of any pulse, chest compressions are provided at an adequate rate and depth that will allow adequate chest recoil, with minimal interruptions in chest compressions. 44. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client? a) assess the patency of the airway b) check tubes or drains for patency c) check the dressing to assess for bleeding d) assess the vital signs to compare with preoperative measurements. 44) A - The first action of the nurse is to assess the patency of the airway and respiratory function. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. If the airway is not patent, the nurse must take immediate measures for the survival of the client. Options B, C, and D are all nursing actions that should be performed after a patent airway has been established. 45. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses for preeclampsia to eclampsia, the nurse's first action should be to: a) administer oxygen by face mask b) clear and maintain an open airway c) administer magnesium sulfate intravenously d) assess the blood pressure and fetal heart rate 45) B - The immediate care during a seizure (eclampsia) is to ensure a patent airway. Options A, C, and D are actions that follow or are implemented after the seizure has ceased. 46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first? a) a primiparous client in the active stage of labor b) a multiparous client who was admitted for induction of labor c) a client who is not contracting, but has suspected premature rupture d) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

46) D - Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options A, B, and C because these clients conditions represent stable ones. 47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to: a) turn on the apnea and cardiorespiratory monitors b) connect the resuscitation bag to the oxygen outlet c) set up the intravenous line with 5% dextrose in water d) set the radiant warmer control temperature at 36.5C (97.6F) 47) B- The highest priority on admission to the nursery for a newborn with a low Apgar scores is the airway, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower priority. The newborn infant will be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress. 48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be risk for: a) infection b) aspiration c) activity intolerance d) altered growth and development 48) A - Initial care of the newborn with myelomeningocele involves prevention of infection. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Activity intolerance and risk for aspiration would not be priority problems with this defect. Risk for altered growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period. 49. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to: a) notify the physician b) turn the child to the side c) maintain an NPO status d) administer the prescribed antiemetic 49) B - After tonsillectomy, if bleeding occurs, the nurse turns the child to the side and then notifies the physician. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side. 50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster? a) the nurse who never had rubeola b) the nurse who never had mumps c) the nurse who never had chickenpox

d) the nurse who never had german measles 50) C - Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Options A, B, and D are unrelated to the herpes zoster virus. 51. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority intervention? a) maintains an intravenous access b) ensures that oxygen is being delivered c) administers sedation to prevent claustrophobia d) provides emotional support to the client's family 1) B - Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority. 52. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assessment is of highest priority? a) monitoring of heel breakdown b) monitoring of bladder distention c) monitoring of extremity shortening d) monitoring for loss of blanching ability of toe nailbeds 2) D - With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially life-threatening complications. 53. A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first? a) call a code b) prepare for cardioversion c) prepare to defibrillate the client d) check the client's level of consciousness 3) D - Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps to determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then the ABCDs airway, breathing, circulation, defibrillation of cardiopulmonary resuscitation or basic life support are initiated. 54. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing intervention after central line insertion? a) prepare the client for a chest radiograph

b) assess the client's temperature to monitor for infection c) label the dressing with the date and time of catheter insertion d) monitor the blood pressure to assess for fluid volume overload 4) A - A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Labeling the dressing site is important but is not the priority. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a c5oncern until IV fluids are started. 55. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which assessment finding? a) temperature 99.4F, flat affect b) fist clenched and pounding table c) tearful, withdrawn, and isolated d) blood pressure 160/100 mmHg; pulse 120 bpm, respirations 18 breaths per minute 5) B - Anxiety can lead to behavior that is harmful to the client and others. If safety is threatened, this is the priority. Tearfulness, withdrawal, isolation, and elevated vital signs are abnormal findings. However, these findings are not life-threatening, although they should be monitored. After the client's mental status is addressed and the client's safety is ensured, the nurse should attend to the elevated vital signs. 56. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the client's: a) level of consciousness b) pulse and blood pressure c) respiratory rate and depth d) ability to move extremities 56) C - The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option B), followed by evaluation of the neurological status (options A and D). 57. A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority nursing action in the plan? a) monitor intake and output b) assess the tissue at the surgical site c) monitor the area for numbness or tingling d) assess the complete blood cell count results 57) C - The priority nursing action is to monitor the affected area for numbness or tingling. Options A, B, and D are also a component of postoperative care, but, from the options presented, are not the priority. 58. A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment? a) pain level b) mobility level c) respiratory status

d) pupillary response 58) C- All of these assessments would be performed on a client with a suspected spinal cord injury. However, respiratory status is the priority. 59. A 52-year old male client is seen in the physician's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg?dL. Which of the following questions should the nurse ask the client first? a) do you exercise regularly? b) are you considering trying to lose weight? c) is there a history of diabetes mellitus in your family? d) when was the last time you had your blood pressure checked? 59) D - The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors. 60. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebra (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit? a) listen to breath sounds b) observe for dyskinesias c) take the client's temperature d) assess extremity muscle strength 60) A - Because compromise of respiration is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorders, so they are not as important in spinal cord-injured clients, unless head injury accompanies the spinal cord injury. 61. A client received a thermal burn caused by the inhalation of steam. The client's mouth is edematous and the nurse notes blisters in the client's mouth. The nurse first assesses which priority item(s)? a) neurological status b) level of consciousness c) temperature via the rectal route d) respiratory status and lung sounds 61) D - Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and generally appear erythematous and edematous with mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. Assessment of respiratory status is the priority. Although the nurse would check the client's temperature and the client's neurological status, respiratory status is the priority.

62. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and a nursing assistant (NA). The nurse assigns which client to the LPN a) client with dementia b) a 1-day postoperative mastectomy client c) a client who requires some assistance with bathing d) a client who requires some assistance with ambulation 62) B - Assignment of tasks needs to be implemented based on the job description of the LPN and NA, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The nursing assistant has the skills to care for a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation. 63. A client requests pain medication and the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, the nurse does which of the following first? a) washes the hands b) removes the gloves c) applies gentle pressure to the injection site d) places the syringe in the secure, puncture-resistant needle box container 63) C - Following administration of an intramuscular injection, the nurse would apply gentle pressure to the site to assist in medication absorption and prevent bleeding. Then, the nurse assists the client to a comfortable position. The uncapped needle and syringe are discarded in a secure, puncture-resistant container, gloves are removed, and the hands are washed. Of the options provided, the nurse would perform option C first. 64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant? a) collecting a urine specimen from a client b) obtaining frequent oral temperatures on a client c) accompanying a man being discharged d) assisting a postcardiac catheterization client who needs to lie flat to eat lunch 64) D- Work that is delegated to others must be consistent with the individual's level of expertise and licensure, if any. Based on the options provided, the least appropriate activity for a nursing assistant would be assisting the postcardiac catheterization client. Because this client needs to eat while lying flat, the client is at risk for aspiration. The remaining three options do not include situations that indicate that these activities carry foreseeable risk. 65. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant? a) a client requiring dressing changes b) a client requiring frequent ambulation c) a client on a bowel management program requiring rectal suppositories and a daily enema d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures 65) B- Assignment of tasks to the nursing assistant needs to be made based on job description, level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. The client described in option 2 has needs that can be met by a nursing assistant.

66. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which of the following is the most appropriate initial nursing action? a) notify the physician of the client's request b) discuss the client's request with the client's family c) document the client's request in the home care nursing care plan d) conduct a client conference with the home care staff to share the client's request 66) A- External cardiac resuscitation is a life-saving treatment that a client may refuse. The most appropriate initial nursing action is to notify the physician, because a written "do not resuscitate" (DNR) order from the physician is needed to ensure that the client's wishes are followed. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, an D may be appropriate, remember that obtaining a written physician's DNR order must be completed first. 67. A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which preprocedure assessment would be of highest priority? a) allergy to iodine or shellfish b) whether the client wishes to void before the procedure c) ability of the client to remain still during the procedure d) whether the client has any remaining questions about the procedure 67) A - Because of the risk associated with allergy to contrast medium, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort. 68. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change on a client. The appropriate action by the RN is to: a) perform the procedure with the LPN b) request that the LPN observe another LPN perform the procedure c) ask the LPN to review the materials from the in-service before performing the procedure d) instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference 68) A - The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions following the procedure. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure. 69. A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries? a) fractured tibia b) penetrating abdominal injury c) bright red bleeding from a neck wound d) open massive head injury to deep coma

69) C - The client with bright red (arterial) bleeding from a neck wound is in "immediate" need of treatment to save the client's life. This client is classified as an emergent client and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of "expectant" would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded "black" in the triage process. The client who is color-coded "black" is given supportive care and pain management but is given definitive treatment last. 70. A nurse working on an adult nursing unit is told to review the client census to determine which client could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the client with which of the following problems would need to remain hospitalized? a) laparoscopic cholecystectomy b) fractured hip, pinned 5 days ago c) diabetes mellitus with blood glucose at 180 mg/dL d) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid) 70) D - The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home 71. A nurse is called to a client's room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the client's wastebasket. The first nurse removed the client from the room. What is the second nurse's next action? a) confine the fire b) evacuate the unit c) extinguish the fire d) activate the fire alarm 71) D - Remember the acronym RACE (i.e., rescue, alarm, confine, extinguish) to set priorities if a fire occurs. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm. 72. A client with type 2 diabetes mellitus is being discharge from the hospital after an occurrence of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The nurse develops a discharge teaching plan for the client and identifies which of the following as a priority? a) exercise routines b) controlling dietary intake c) keeping follow-up appointments d) monitoring for signs of dehydration 72) D- Clients at risk for HHNS should immediately report signs and symptoms of dehydration to health care providers. Dehydration can be severe, and it may progress rapidly. Although options A, B, and C are components of the teaching plan, for the client with HHNS, dehydration is the priority. 73. A client is receiving intralipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The health care nurse makes a visit and discusses potential adverse

reactions and the side effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of suspected adverse reaction, the priority action is to: a) stop the infusion b) contact the nurse c) take the client's blood pressure d) contact the local area emergency response team 73) A - Fat-emulsion therapy can cause overloading syndrome (i.e., focal seizures, fever, and shock) and adverse effects, including chest pain, chills, and shock. The priority action is to stop the infusion to limit the adverse response. Although options B, C, and D are correct interventions, the priority is to stop the infusion. 74. The nurse caring for a client who is dying formulates a nursing diagnosis of Fear and identifies appropriate nursing interventions. From the following list of nursing interventions, which intervention should the nurse implement first? a) help the client express fears b) assess the nature of the client's fear c) help the client identify coping mechanisms that were successful in the past d) document verbal and nonverbal expressions of fear and other significant data 74) B - Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention. 75. A nurse reviews the preoperative teaching plan for a client scheduled for a radical neck dissection. When implementing the plan, the nurse initially focuses on: a) the financial status of the client b) postoperative communication techniques c) information given to the client by the surgeon d) the client's support system and coping behaviors 75) D- The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation but also to determine the starting point for teaching and to implement the education at the client's level. Although options A, B, and D may be components of the plan, they are not the initial focus. 76. A nurse in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant? a) a client on strict bedrest for whom a 24-hour urine specimen is being collected b) a client scheduled for transfer to the hospital for coronary artery bypass surgery c) a client scheduled for transfer to the hospital for an invasive diagnostic procedure d) a client who is going through rehabilitation after undergoing a below-the-knee amputation (BKA) 76) A- The nurse must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a BKA, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive

diagnostic procedure will require strategies to meet both physiological and psychosocial needs. The nursing assistant has been trained to care for a client on bedrest and to maintain 24-hour urine collections. The nurse would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant. 77. A client has received electroconvulsive therapy (ECT). In the post-treatment area and upon the client's awakening, the nurse will perform which intervention first? a) assist the client from the stretcher to a wheelchair b) orient the client and monitor the client's vital signs c) offer the client frequent reassurance and repeat orientation statements d) check for a gag reflex and then encourage the client to eat breakfast and resume activity 77) B - The nurse would first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in options A, C, and D will follow accordingly. 78. A nurse has assisted the physician in placing a central (subclavian) catheter. Following the procedure, the nurse takes which priority action? a) ensures that a chest radiograph is done b) obtains a temperature reading to monitor for infection c) labels the dressing with the date and time of catheter insertion d) monitor the blood pressure (BP) to check for fluid volume overload 78) A - A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. While a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. While BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important, but it is not a priority action in this situation. 79. A nurse is caring for a hospitalized client with a diagnosis of abruptio placentae. The nurse develops a nursing care plan and suggests measures to be implemented in the event of the development of shock. The nurse documents that the initial nursing action in the event of shock is which of the following? a) turn the client onto her side b) check the client's blood pressure c) monitor urinary output d) check the client's heart rate 79) A- With a client in shock, the goal is to increase perfusion to the placenta. The priority nursing action would be to turn the client onto her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. Options B, C, and D are also interventions that would be implemented following this initial action. 80. A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of four nursing diagnoses. Which would the nurse select as the priority?

a) activity intolerance b) ineffective coping c) imbalanced nutrition: less than body requirements d) deficient fluid volume 80) D - For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the respiratory system and placenta. Deficient fluid volume would be the priority nursing diagnosis followed by Imbalanced nutrition. Activity intolerance and Ineffective coping may compete regarding the third and fourth priorities depending on the specific client symptoms at the time of care. 81. An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and places a gown on the client to prepare the client for the surgical procedure. Which of the following indicates the appropriate nursing action regarding the client's clothing, which is stianed with blood? a) discard clothing b) give the clothing to the family member or significant other c) place the clothing in a paper bag d) place the clothing in a plastic bag and in a locked cabinet 81) C- All evidence discovered during an examination is recorded. Documentation of evidence includes the bodily location from which the sample was obtained and when or to whom it was delivered. Evidence should be maintained in its original condition. Clothing is stored in a paper bag instead of plastic to prevent decomposition. If clothing needs to be cut off the client, special attention is taken not to destroy evidence inadvertently. 82. A nurse is assessing a client who has a suspected spinal cord injury. Which of the following is the priority assessment? a) pupillary response b) respiratory status c) mobility d) pain 82) B - All of the assessments in the options would be performed on a suspected spinal cord injury client; however, respiratory status is the priority. 83. When delegating a task to a team member, the nurse as the team leader gives authority over the task by: a) offering suggestions on how to complete the task b) waiting for the team member to report the results of the completed task c) completing the task for the team member d) checking to be sure the task is complete 83) B- Authority for task completion is given to the team member by not directing or participating, and allowing the team member to complete the task under her own responsibility. The team member then reports the results to the team leader. Options A, C, and D involve the team leader in task completion. 84. A nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled fro a cardiac catheterization. Following the catheterization, the priority nursing action is to assess the:

a) catheter insertion site b) temperature c) potassium level d) urine output 84) A- During the post cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses also are assessed. Potassium level, temperature, and urine output should also be monitored but are not the priority of the items identified in the options. 85. A nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. The priority consideration in planning activities for the child is to ensure: a) social interactions with other children in the same age-group b) safety with activities c) familiarity with all activities and providing orientation throughout the activities d) activities that provide verbal stimulation 85) B- Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal communications, and providing familiarity with activities and orientation are also appropriate interventions, the priority is safety. 86. A nurse employes in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant? a) a client who had a below-the-knee amputation b) a client on a 24-hour urine collection who is on strict bedrest c) a client scheduled to be transferred to the hospital for coronary artery bypass surgery d) a client scheduled for transfer to the hospital for an invasive diagnostic procedure 86) B - The nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nursing practice acts and the job descriptions of the employing agency. A client who had a below-the-knee amputation, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will have physiological as well as psychosocial needs. The nursing assistant is trained to care for a client on bedrest and on a urine collection. 87. The parents of an 18-month-old child arrive at the emergency department with the child. The child is unconscious. The physical examination reveals bruises on the child's upper arms that resemble grip marks, and the nurse suspects child abuse. The first priority of the nurse is to: a) contact the appropriate state officials to report the abuse case b) establish a trusting relationship with the parents c) secure a safe environment for the child d) stabilize the child's physical condition 87) D - In all child abuse cases, the primary concern is the health and safety of the child. Although all of the options are correct, this child is experiencing a medical crisis (unconsciousness); therefore, the first priority is to stabilize the child's condition. Because the child's future health and safety depend on the family, it is critical that the nurse establish a trusting relationship with the parents and collaborate on developing goals that are mutually acceptable. Cases of suspected abuse are reported.

88. A nurse is planning care for a client with an obsessive-compulsive disorder. The nurse would assign the highest priority to which of the following nursing interventions? a) educate the client about self-control techniques b) establish a trusting nurse-client relationship c) monitor the client for abnormal behavior d) encourage participation in daily self-care and unit activities 88) B- A trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. The nursing interventions identified in each of the other options may be appropriate but are not of the highest priority. 89. A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility following delegation of the tasks is to: a) allow each staff member to make judgements when performing the tasks b) follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task c) document that the task was complemented d) assign the tasks that were not completed to the next nursing shift 89) B - The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift. 90. A client who has had abdominal surgery calls the nurse and reports that she felt that "something gave way" in the abdominal incision. The nurse checks the abdominal incision and notes the presence of wound dehiscence. The nurse should take which action first? a) contact the physician b) document the findings c) place the client inlow-fowler's position and instruct the client to lie quietly d) cover the abdominal wound with a sterile dressing moistened with sterile saline solution 90) C - Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowler's position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified, and the nurse documents the occurrence and the nursing actions implemented.

d) obtain a flashlight, gauze, and a curved hemostat 91) A - Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon. 92. A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to: a) ensure that the intravenous (IV) line is patent b) prepare the client for a perfusion scan c) administer nasal oxygen d) place the client on a cardiac monitor 92) C - Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen. 93. An older client with a history of hyperparathyroidism and severe osteoporosis is newly hospitalized. The nurse reviews the plan of care for the client and selects which nursing diagnosis as the priority? a) risk for injury b) impaired urinary elimination c) risk for constipation d) ineffective health maintenance 93) A - The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history and whether the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a concern but is not the priority. 94. A client arrives at the nursing unit following internal maxillary fixation (IMF) surgery. The immediate nursing action is to: a) administer an anti-emetic to prevent vomiting b) position the client on the side with the head slightly elevated c) place wire cutters at the bedside d) connect the nasogastric tube (NGT) to allow intermittent suction 94) B- Immediately after IMF surgery, the client is positioned on his side, with the head slightly elevated. The nurse then connects the NG tube to low intermittent suction. Antiemetic medications are administered to prevent vomiting, but this is not the immediate action. Wire cutters should already have been placed at the bedside. 95. A registered nurse is planning the client assignments for the day. Which of the following is the appropriate assignment for the nursing assistant?

91. A nurse is caring for a client who just returned from the recovery room after a tonsillectomy and adenoidectomy. The client is restless and the pulse rate is elevated. The nurse prepares to continue assessing the client, but the client begins to vomit large amounts of bright red blood. The immediate nursing action is to: a) notify the surgeon b) continue with the assessment c) check the client's temperature

a) a client requiring frequent vital signs following a cardiac catheterization b) a client who requires frequent ambulation c) a client requiring wound irrigation d) a client receiving continuous tube feedings 95) B - The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who has had a cardiac catheterization will require specific monitoring in addition to vital signs. Unlicensed personnel do not perform wound irrigations and tube feedings. 96. A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical nurse (LPN) and three nursing assistants on a nursing team. Which of the following clients would the nurse appropriately assign to the LPN? a) a client with a right leg amputation who requires assistance with a shower b) a client requiring a bed bath and frequent ambulation with a walker c) a client who requires frequent temperatures taken d) a client with a decubitus ulcer that requires a wound irrigation and dressing change 96) D- When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, give a bed bath, ambulate a client with a walker, and take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member. 97. A registered nurse (RN) has received the assignment for the day shift. After making initial rounds and checking all the assigned clients, which client will the RN plan to care for first? a) a postoperative client with chest tubes who has just received pain medication b) a client scheduled for a chest x-ray at 11:00 AM c) a client who is scheduled for surgery at 1:00 PM d) a client who is self-care 97) C - The RN would plan to care for the client who is scheduled for surgery at 1:00 PM first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, often the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is self-care and the client scheduled for an x-ray later in the morning do not have priority needs related to care. 98. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? a) a client admitted on the previous shift with a diagnosis of gastroenteritis b) a client in skeletal traction c) a client attached to a ventilator d) a postoperative client preparing for discharge 98) C - Airway is always a high priority, and the nurse would assess the client attached to a

ventilator first. The clients described in options A, B, and D have needs that would be identified as intermediate priorities. 99. A nurse on the day shift is assigned to care for four clients. Following report from the night shift, which client will the nurse plan to asses first? a) client scheduled for a cardiac catheterization at 10:00 AM b) client newly diagnosed with diabetes mellitus who is scheduled for discharge to home c) client with pulmonary edema who was treated with furosemide (Lasix) at 5:00 AM d) client scheduled to have an electrocardiogram (ECG) at 9:00 AM 99) C - Airway is always a high priority, and the nurse would assess the client with pulmonary edema who was treated with furosemide at 5:00 am first. The nurse would next assess the client scheduled for the cardiac catheterization, followed by the client scheduled for discharge and the client scheduled for an ECG. 100. A registered nurse (RN) is planning the client assignments for the day. The RN assigns which of the following clients to the nursing assistant? a) a client who needs range-of-motion exercises every 4 hours b) a client who needs to be catheterized every 12 hours c) a client who needs to be suctioned as needed (PRN) d) a client who needs a dressing change performed every 4 hours 100) A- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the tasks is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Noninvasive interventions can be assigned to a nursing assistant. Options B, C, and D can be assigned to a licensed practical nurse or another RN because these staff members can perform certain invasive procedures. 101. A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the LPN? a) a client who needs assistance with grooming b) a client who needs frequent ambulation c) a client who needs to be suctioned as needed (PRN) d) a client who needs assistance with hygiene measures 101) C- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Option C can be assigned to the LPN because this staff member can perform certain invasive procedures. Noninvasive interventions can be assigned to a nursing assistant. These include the tasks identified in options A, B, and D. 102. A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant? a) assisting a profoundly developmentally disabled child to eat lunch b) obtaining frequent oral temperatures on a client c) accompanying a 51-year old man, being discharged to home following a bowel resection d) collecting a urine specimen from a 70-year old woman admitted 3 days ago 102) A - The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a

nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore a higher potential for complications such as choking and aspiration. The remaining three options include no data indicating that these tasks carry any unforeseen risk. 103. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? a) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift b) a postoperative client preparing fro discharge c) a client scheduled for a chest x-ray d) a client requiring daily dressing changes 103) A - Airway is always a high priority, so the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options B, C, and D would be an intermediate priority. 104. A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant? a) a client requiring twice -daily dry dressing changes b) a client requiring frequent ambulation with a walker c) a client on a bowel management program requiring rectal suppositories and a daily enema d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures 104) B - Assignment of tasks needs to be implemented on the basis of the job description of the nursing assistant, the level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. Although a nursing assistant may be trained to administer an enema (depending on state practice acts and agency policy), a rectal suppository needs to be administered by a licensed nurse. Option B is the most appropriate assignment for the nursing assistant. 105. A client with a spinal cord injury develops a severe, pounding headache. The client is diaphoretic, hypertensive, and bradycardic and complains of nausea and nasal congestion. The nurse determines that the client is experiencing autonomic hyperreflexia (autonomic dysreflexia). Which action would the nurse take first? a) notify the physician b) document the findings c) perform a rectal examination d) place the client in a sitting position 105) D - Autonomic hyperreflexia is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction), or stimulation of the skin. When autonomic hyperreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse would then perform a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately via a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or broken skin. The physician is notified, and the nurse documents the occurrence and the actions taken.

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