The nurse receives report on 4 assigned clients. which client should the nurse assess first

The nurse in the outpatient clinic has four phone messages. Which message should the nurse return FIRST?

A client with a spinal cord injury at the level of C6 complains of a headache

The nurse sees patients in the gastrointestinal clinic. Which of the following patients should the nurse see FIRST?

A newborn experiencing projectile vomiting and irritability.

The nurse prepares assignments for a group of clients. Which care does the nurse delegate to the nursing assistive personnel (NAP)? Select all that apply. (3)

1( Collect a stool specimen from a client with suspected Clostridium difficile.
2) Obtain and documenting blood pressure readings on an adult with hypertension
3) Provide a back massage to a client with chronic pain.

A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions?

“What are your specific concerns?”

The nurse prepares 0900 medications for a 90-year-old client who was recently transferred from an assisted care facility. The nurse will use which actions to identify the client to ensure the correct client receives the medication? (4)

Ask the client to state the client's name.
Check the name on the client's identification band.
Compare the client to a photo of the client in the chart.
Scan the bar code on the client's ID bracelet.

It is MOST important for the nurse to consider which of the following concepts when planning nursing care for a client from a culture other than the United States?

The concept of time and the organization of society in the client’s native country.

A nurse notes a significant increase in client falls causing injury. To help resolve this problem, which of the following actions by the nurse is MOST appropriate?

Form a group to design and implement a plan to prevent further incidents.

The staff on the medical/surgical unit consists of two RNs, one LPN/LVN, and one nursing assistant. The charge nurse determines care is appropriate if which of the following tasks is delegated to the nursing assistant?

Implement bladder training measures for a client with urinary incontinence.

The nurse cares for clients in the neurological trauma unit. The nurse learns that a new admission was responsible for the death of a neighbor during a robbery. The nurse says to the head nurse, “I don’t think that I can care for that client.” Which of the following responses by the head nurse is BEST?

“Please share with me your concerns.”

A client diagnosed with acute streptococcal glomerulonephritis (ASGN) visits the nurse at the university health center. The client is receiving captopril (Capoten) 25 mg PO and is concerned about side effects. Which of the following responses by the nurse is BEST?

“What are your concerns?”

The 21 year old student refuses to seek medical evaluation. It is MOST appropriate for the nurse to take which of the following actions?

Tell the student he does not have to seek medical evaluation if he does not want to.

The nurse receives a report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?

A client admitted from the emergency department 1 hour ago with multiple injuries due to a motor vehicle accident.

The client is an investment banker and his company filed for bankruptcy two weeks ago. After the business employee leaves, the client goes to the nurse’s station to complain that his right to privacy was violated. Which of the following actions should the nurse take FIRST?

Escort the client to a private setting.

The nurse is assisting a newly registered nurse in learning client care management and delegation. The nurse counsels the new nurse when which actions are observed?  Select all that apply. (3)

The new nurse asks the nursing assistive personnel (NAP) to obtain the blood glucose level on a newly diagnosed diabetic client just admitted to the unit, vitals after heart cath, MG first meal

The nurse educator prepares a class on crisis management. It is MOST important for the nurse to emphasize which of the following principles?

One person should be in charge during a crisis.

The nurse in the newborn nursery receives report from the previous shift. Which infant should the nurse see first?

A 32-year-old scheduled for a mastoidectomy.

The nurse in the newborn nursery receives report from the previous shift. Which infant should the nurse see first?

A 2-day-old infant, lying quietly alert, heart rate of 185 bpm.

The nurse supervises a new graduate nurse, who cares for a client who has developed stroke symptoms while in the emergency department (ED). Which actions by the graduate nurse cause the nurse to immediately intervene? Select all that apply. (3)

1) admin 325 of aspirin
2) assisgns client score of 0 on NIH stroke scale
3) reassures client that symptoms will go away

screening for glaucoma. Tonometry indicates that four residents have elevated intraocular pressure (IOP). The nurse contacts the local ophthalmologist and learns that only one appointment is available during the next 7 days. It is MOST important for the nurse to refer which of the following residents?

A resident with type 1 diabetes and an IOP of 26 mm Hg.

The nursing team consists of a nurse, an LPN/LVN, and 2 nursing assistive personnel (NAP). Which client care activities does the nurse recognize as best utilizing the LPN/LVN’s skill set? Select all that apply. (2)

1) Suction a client’s tracheostomy.
2) Care for a 2-year-old client who has a systolic blood pressure of 84 mmHg.

The nurse on the medical/surgical unit notes a graduate nurse often seems rushed during the shift and is staying overtime without pay to complete work. The graduate nurse approaches the nurse and says, "I am having difficulty with time management." Which of the following INITIAL responses by the nurse is BEST?

"What ideas do you have as to the reasons for your time management difficulties?"

At a rehabilitation center for spinal-cord-injured (SCI) clients, the nurse conducts an orientation session for a group of nursing assistive personnel (NAP). Which statement is most important for the nurse to include?

“Obtain the client’s permission before touching the client.”

The nurse cares for clients on the medical/surgical floor. Which of the following clients should the nurse assign to the LPN/LVN?

A client diagnosed with cellulitis receiving antibiotics.

The nurse cares for the client with rheumatoid arthritis. The nurse prepares for the client to be discharged. The nurse knows that for the client to manage at home alone the client needs to be able to perform which activity?

Comb hair and brush teeth.

The nurse is caring for clients in the diabetic clinic. Which client should the nurse see FIRST?

The client with sunken eyeballs and a fruity breath odor.

The nurse’s elderly mother-in-law arrives at the nurse’s home for a short visit. The mother-in-law informs the nurse that the numbers on the house need to be replaced because pieces of the wood appear to be missing. Which of the following responses by the nurse is MOST appropriate?

“I’ll check to see if the house numbers are visible.”

The 75-year-old client is admitted with altered mental status and a urinary tract infection. The health care provider(HCP) writes an order for use of a Posey vest restraint. Which action by the nurse is best?

Reevaluate the client’s need for the restraint every 4 hours.

The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate?

“Please tell me more about your concerns.”

The nurse cares for clients in the outpatient clinic. Each of the following clients has asked to see the nurse due to complaints of pain. Which of the following clients should the nurse see FIRST?

A client with a history of coronary artery disease (CAD) who complains of midepigastric pain radiating to the neck.

The triage nurse at a busy urgent care center prioritizes clients for evaluation. The nurse determines that which of the following clients should be seen FIRST?

A woman at 6 weeks’ gestation who complains of left lower quadrant abdominal pain and vaginal spotting.

The nurse in the outpatient clinic receives a phone call from a young adult who says that her friend has overdosed. Which of the following actions should the nurse take FIRST?

Determine if the client is responsive.

The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN?  Select all that apply.

1)A client following L-4 to L-5 laminectomy with a history of breast cancer.
2) A client diagnosed with multiple sclerosis with increased bilateral leg weakness.
3) herpes zoster ophthalmicus and dementia.

The nurse reviews clients' current lab values. Which clients require further assessment? Select all that apply.

1) The client diagnosed with an acute kidney injury whose serum creatinine has increased from 1.8 to 2.6 mg/dL (159.12 to 229.84 µmol/L).
2) The client being treated for dehydration whose urine specific gravity has increased from 1.020 to 1.040.

The nurse receives report on the following patients upon arrival at the medicine unit. Which of the following patients should the nurse see FIRST?

A patient complaining of frequent small amounts of watery diarrhea with abdominal pain and nausea.

The nurse administers medication. While documenting the administration, the nurse realizes an error in administration. Which actions must the nurse take? (4)

1) Evaluate the effect of the medication.
2) Notify the patient's health care provider.
3) Notify the patient of the error.
4) Complete an occurrence report

The nurse who is caring for patients in the outpatient clinic receives four phone calls. Which of the following calls should the nurse return FIRST?

The father of a toddler calls to report that his child swallowed a dime.

The nurse manager wants to increase the number of nurses on the unit. This will require precepting the new nurses. Which actions does the nurse manager take? Select all that apply. (3)

Requests permission from administration to grant incentives for nurses that serve as preceptors.
2) Surveys the nurses on the unit to find out the perceived pros and cons of being a preceptor.
3) Reviews nursing management literature to discover ways to increase nurse's willingness to be preceptors.

The evening shift nurse reviews the client care activities performed by the LPN/LVN during the day shift. Which of those activities draw the nurse's concern since they should not be performed by an LPN/LVN? Select all that apply. (4)

Provided care to a client diagnosed with partial-thickness and full-thickness burns.
Modified a client’s plan of care.
Provided care to a client diagnosed with plumbism.
Titrated an intravenous infusion under the direction of a pharmacist.

The nurse on the medical/surgical unit prepares several clients for discharge today. Which of the following statements, if said by one of the clients to the nurse, indicates the need for further teaching?

"Now that I’ve had this old hip replaced, I can get back on the tennis court."

The nurse receives report on the client who had a stroke and is aphasic with a Do Not Resuscitate (DNR) order. Initial assessment reveals pulse is 102 bpm, respirations 28 rpm, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally and O2 sat 84% on O2 at 4 L by nasal cannula. Which actions does the nurse NOT do

place client in high Fowler's
-- HOB only 15-20 degrees

The nurse makes client care assignments for the day. Which activities can the nurse properly delegate to nursing assistive personnel (NAP)? Select all that apply. (2)

1) Ambulate a client who has a lower limb prosthesis.
2) Pad the side rails for a client who had a seizure.

After receiving report from the night shift, the nurse plans assignments for the day on the pediatric unit. Which of the following patients should the nurse see FIRST?

A patient diagnosed with hemophilia complaining of joint pain.

The nurse observes that a health care provider has ordered 100 mL D5W with KCl 80 mEq to infuse in 30 minutes. Which action should the nurse take first?

Contact the health care provider.

The nurse receives a phone call from a neighbor’s teenaged son telling the nurse that his dad (age 47 years) has been experiencing severe midsternal chest pain for 15 minutes. The teen cannot get his father to seek medical assistance. Which of the following activities should the nurse perform FIRST?

Contact the neighbor and tell him that his son asked the nurse to see his father.

The nurse delegates tasks in the emergency department. Which tasks can the nurse properly delegate to nursing assistive personnel (NAP)? Select all that apply. (4)

Measure the diameter of the client’s calf.
Obtain a midstream urine specimen.
Cleanse a superficial wound with an antiseptic solution.
Measure a client’s rectal temperature.

The nurse receives a report from the previous shift. Which of the following patients should the nurse see FIRST?

A patient who had a laryngectomy 12 hours ago.

Which information is essential to report when communicating client information at the change of shift?  Select all that apply. (3)

The client is newly diagnosed with type 1 diabetes and needs follow-up teaching about insulin administration.
The client is more confused and has been attempting to get out of bed without assistance.
health care provider ordered lorazepam PRN for restlessness.

The nurse asks the nursing assistant to perform soapsuds enemas for a patient scheduled for a diagnostic test. The nurse should

ask the nursing assistant to describe the returns from the enemas.

The nurse coordinates care on the medical-surgical unit. Which clients would the nurse have to assign to the LPN/LVN for the nurse to be considered professionally negligent? Select all that apply. (3)

Client with hemoglobin 6 g/dL (60 g/L).
Client with blood urea nitrogen 80 mg/dL (28.56 mmol/L).
Client with platelet count 22,000/mm3.

The nurse is approached by transport personnel asking the nurse to sign out a client for transport for magnetic resonance imaging (MRI). The client states “I was in a car accident and there is something wrong with my left eye.” Which of the following responses by the nurse to the transport personnel is MOST appropriate?

“You have to talk with the nurse assigned to the client.”

Which of the following clients should the nurse assess first?

Which client would the nurse assess first after a shift report?

Which client would the nurse prioritize when triaging clients in the emergency department?

Which client should the charge nurse assign to the room closest to the nurse's station?