Prioritzation and Delegation Test bank|NURS 462 Prioritzation and Delegation Practice Questions and Answers_Latest Fall 2020.

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Prioritization and Delegation Test Bank 1. The charge nurse assigns two RNs to provide care as a team for laboring patients. What are the supervisory needs of each of these? a) Because they have ... equal status, each RN is responsible for supervising the other RN. b) Supervision is not necessary because each RN is responsible and accountable for his/her own practice. c) RNs cannot delegate to other RNs, so supervision is not possible in this situation. d) The charge nurse who made the assignment is responsible for supervising each of the RNs. 2. In determining the competencies of staff to whom the registered nurse may delegate, the RN should review the annual staff competencies required by: a) Licensing bodies such as the American Nurses Association b) American Association of Critical Care Nurses c) Accrediting agencies such as the Joint Commission d) Third party payers such as Medicaid and private insurers 3. Which of the following would have the highest priority when one is determining to whom to delegate a task? a) How many times the person has performed the task b) Whether the employee wants to perform the task c) The amount of time needed to complete the task d) The credentials of the person to whom the task is being delegated 4. An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply.) a) Perform trach care b) Administer medications via metered-dose inhaler (MDI) c) Complete in-depth admission assessment d) Initiate the nursing care plan e) Reinforce teaching for using MDI’s 5. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? a) Assign an RN to perform all sterile procedures. b) Assign an LPN to give all IV medications. c) Assign an UAP to complete the a.m. care. d) Assign an LPN to write the care plans. 6. The nurse is assigned to the following clients. Which client should be assessed first? a) A client admitted to the hospital for observation who has absent bowel sounds. b) A 24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system. c) A client with CHF who has a 4 lb weight gain since yesterday and is experiencing shortness of breath. d) A client who is undergoing surgery for a hysterectomy on the following day. 7. The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first? a) Notify the healthcare provider immediately. b) Have the UAP recheck the client’s vital signs manually. c) Place the client in Trendelenburg position. d) Assess the client’s cardiovascular status. 8. The patient's spouse is frustrated and tells the nurse, "Everyone is telling me something different as to when my wife is going to be able to go home. I don't know who to believe." Which statement is the nurse's best response? a) “I see can see you are frustrated. Would you like to talk about how you feel?” b) “I will contact the case manager and have her talk to you as soon as possible.” c) “Don’t worry. Your wife won’t go home until both you and she are ready.” d) “Your wife’s healthcare provider should be able to give you all that information.” 9. The clinic nurse is caring for a 10-year-old boy with a diagnosis of type 2 diabetes being managed with therapeutic lifestyle change. Which problem is priority? a) Altered nutrition-excessive intake b) Risk for low self-esteem c) Hypoglycemia d) Risk for loss of body part 10. The overhead page has just announced a Code Red, actual fire, on a unit two floors below the unit where the nurse is working. Which action should the nurse implement first? a) Turn off oxygen supply to the rooms. b) Evacuate the patients to a lower floor. c) Close all of the doors to the patient’s rooms. d) Make a list of patients ready for discharge. 11. The nurse has received the shift report. Which client should the nurse assess first? a) The client with a deep vein thrombosis who is complaining of dyspnea and coughing. b) The client diagnosed with Buerger’s disease who has intermittent claudication. c) The client diagnosed with an aortic aneurysm who has an audible bruit. d) The client with acute arterial ischemia who has bilateral palpable pedal pulses. 12. The client is admitted with a stroke. The nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting, and feeding. The delegation is appropriate if the RN delegates the tasks of bathing and toileting to which staff member? a) The nursing assistive personnel (NAP, AP, UAP) b) The LPN c) The RN d) The float nurse 13. After receiving night shift’s report, the nurse plans assignments for the day. Which client should the nurse see first? a) A 25-year-old who requires a metered-dose inhaler. b) A 30-year-old with a short arm cast on the left arm. c) A 40-year-old diagnosed with hypothyroidism requiring TSH level. d) A 17-year-old who took 10 methylphenidate and has a blood pressure of 160/100. 14. The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate? a) Request the LPN to escort the client to the examination room. b) Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client. c) Instruct the RN to administer the tetanus shot to the client. d) Tell the clinic secretary to call in a new prescription for a client. 15. A 52-year-old man is receiving IV cimetidine. After 20 minutes, the patient complains of a headache and dizziness. Which of the following actions should the nurse take first? a) Stop the infusion. b) Call the physician. c) Reposition the patient. d) Call the pharmacist. 16. Children from a school bus accident are transferred to the hospital. The nurse triages in the ED. Which child should the nurse see first? a) An 8-year-old with a superficial burn to the arm. b) A 7-year-old with burns on 10% of the total body surface area. c) A 6-year-old with small lacerations to the arms and legs. d) A 5-year-old reporting elbow pain. 17. The nurse enters the room and the client is beginning to have a tonic-clonic seizure. Which action should the nurse implement first? a) Identify the first area that began seizing. b) Pad the siding of the client’s bed rails. c) Provide the client with privacy during the seizure. d) Note the time the client’s seizure began. 18. The UAP tells the nurse the client with thyroid cancer who is terminally ill is having deep-rapid breathing, but then doesn’t breathe for about a minute. Which intervention should the nurse implement first? a) Explain the client is having Cheyne-Stokes respirations. b) Go to the client’s room immediately and assess the client. c) Notify the hospital chaplain to come to the client’s room. d) Contact the client’s family that the client’s death is near. 19. Which task would be most appropriate for the nurse on the GI unit to delegate to the UAP? a) Request the UAP to draw the serum liver function test. b) Ask the UAP to remove the nasogastric tube. c) Tell the UAP to empty the client’s colostomy bag. d) Instruct the UAP to assist the unit secretary to transcribe HCP orders. 20. The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? a) The elderly client who is experiencing a stroke in evolution. b) The client diagnosed with a transient ischemic attack 48 hours ago. c) The client diagnosed with Guillain-Barré syndrome who complains of leg pain. d) The client with Alzheimer’s disease who is wandering in the halls. 21. The client is diagnosed with end-stage congestive heart failure. The home health nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first? a) Assist the client to a sitting position. b) Assess the client’s vital signs. c) Call 911 for the paramedics. d) Auscultate the client’s lung sounds. 22. The charge nurse has one nurse, one LPN, and two nursing assistants on the unit. The charge nurse must delegate responsibilities. Which is the best choice of assignment? a) The nursing assistive personnel should perform suctioning. b) The LPN should change wound dressings. c) The nursing assistive personnel should administer IV medications. d) The nurse should perform bed baths and morning hygiene. 23. The nurse is seeing clients in the medical-surgical unit. Which client will the nurse see first? a) A client diagnosed with heart failure who received 800 mL of IV fluids in 2 hours. b) A client diagnosed with lung cancer with a blood calcium level of 12.5 mg/dL. c) A client diagnosed with hypertension requiring a 0900 dose of captopril. d) A client postoperative after a laminectomy requiring supervision when ambulating. 24. An RN from the psychiatric unit is reassigned to the pediatric unit. Which client assignment is most appropriate for this nurse? a) A child diagnosed with type 1 diabetes admitted with a blood glucose of 370 mg/dL reporting thirst and frequent urination. b) A child diagnosed with hemophilia requiring discharge instructions about appropriate and safe sports. c) A child experiencing separation anxiety who wants to stay home with parent instead of going to school. d) A child with a newly diagnosed brain tumor reporting headaches and left-sided weakness. 25. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? a) The client with acute glomerulonephritis who has oliguria and periorbital edema. b) The client with renal calculi who is complaining of flank pain rated as a 5 on a scale of 1 to 10. c) The client with nephrotic syndrome who has proteinuria and hypoalbuminemia. d) The client with benign prostatic hypertrophy who has blood oozing from the IV site. Patient may be going into DIC which is a potentially life-threatening complication & requires immediate intervention. 26. Which of the following tasks is appropriate for the nurse to delegate to an experienced nursing assistive personnel? a) Obtain a 24-hour diet recall from a client recently admitted with anorexia nervosa. b) Obtain a clean-catch urine specimen from a client suspected of having a urinary tract infection. c) Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection. d) Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange. 27. The nurse cares for clients on the medical surgical unit. Which client should the nurse see first? a) A newly admitted client diagnosed with appendicitis. b) A client who is confused and is restless and yelling. c) A newly admitted client diagnosed with a head injury. d) The client diagnosed with heart failure. 28. At 1000, the client diagnosed with type 1 diabetes is complaining of being jittery, having a headache, and being dizzy. Which intervention should the nurse implement first? a) Provide the client with the lunch meal. b) Request the laboratory to draw a serum glucose level. c) Determine the last time the client received insulin. d) Give the client glucose tablets. 29. Which task is most appropriate for the charge nurse to assign to the LPN? a) Tell the LPN to change the client’s subclavian dressing. b) Request the LPN to obtain the client’s daily weight. c) Assign the LPN to care for the client in myxedema coma. d) Ask the LPN to complete discharge teaching to the client. 30. The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should be assigned to the LPN? a) Feed the client who is being allowed to eat for the first time. b) Administer the client’s anticoagulant subcutaneously. c) Check the client’s neurological signs and limb movement. d) Teach the client to turn the head and tuck the chin to swallow. 31. The nurse just received the a.m. shift report. Which client should the nurse assess first? a) The client who is 6 hours post-op vein ligation who has absent pedal pulses. b) The client diagnosed with deep vein thrombosis who is complaining of calf pain. c) The client with Raynaud’s disease who has throbbing and tingling in the extremities. d) The client with Buerger’s disease who has intermittent claudication of the feet and arms. 32. The nurse is seeing patients in the psychiatric clinic. Which of the following patients should the nurse see first? a) A 15-year-old male brought in by police after threatening to jump off a bridge and has access to a gun. b) A 20-year-old female who lost 2 lbs this week and only eats two meals a day. c) A 45-year-old male with a history of depression who states he is out of Prozac. d) A 75-year-old male whose wife passed away two weeks ago and is experiencing insomnia and irritability. 33. Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning? a) Alteration in bowel elimination. b) Nutrition altered: less than body requirements. c) Fluid and electrolyte imbalance. d) Oral mucous membrane, altered. 34. Which priority intervention should the nurse implement when teaching the client with type 2 diabetes about glucometer checks? a) Instruct the client to keep a written record of the glucometer readings. b) Have the client demonstrate how to correctly perform the glucometer reading. c) Recommend the client check the glucometer reading in the morning. d) Tell the client to dispose of the lancets and strips appropriately. 35. An LPN from the medical-surgical unit is sent to the ED to help. To which client can the LPN be assigned? a) An infant experiencing seizures. b) A pregnant client having a gall bladder attack. c) The client with chest pain. d) The client with an infected surgical wound. 36. The nurse cares for a client who needs several nursing care procedures. Which of the client’s needs should be met first? a) The client has been unable to urinate for the past 10 hours and has a health care provider’s order for a straight catheterization PRN. b) The client’s nasogastric tube needs to be irrigated every 4 hours. It is time for this to be done again. c) The client needs to be transferred from the bed to the chair so that the client can sit up for dinner. d) The client’s patient-controlled analgesia (PCA) pump is empty and needs a new syringe of morphine. 37. Which task is most appropriate for the medical nurse to delegate to the UAP? a) Ask the UAP to escort the client on the PCA pump to the bathroom. b) Tell the UAP to witness the client’s advance directive. c) Request the UAP to take the diabetic client’s HS snack to the client. d) Ask the UAP to show the client how to take the client’s radial pulse. 38. The charge nurse on the endocrine surgical unit is making assignments. Which task should be delegated/assigned to the team members? a) Request the licensed practical nurse (LPN) assess the client who is hypoglycemic. b) Ask the unlicensed assistive personnel (UAP) to assist feeding the client with an adrenalectomy who has a paralytic ileus. c) Instruct the UAP to insert a nasogastric (N/G) tube into the client who has had a thyroidectomy. d) Tell the LPN to perform an in and out catheterization for the client diagnosed with acromegaly. 39. The RN has assessed clients on the psychiatric unit. Which activity is appropriate for the nurse to delegate to a nursing assistive personnel on a psychiatric unit? a) Perform 30-minute check on each client. b) Obtain lithium level on a client who may be toxic. c) Lead a group on anger management with eight clients. d) Administer fluoxetine to a client as ordered. 40. The charge nurse supervises care of clients on the medical/surgical unit. The charge nurse determines care is appropriate if which task is delegated to the nursing assistive personnel? a) The client diagnosed with an ulcer requires the morning dose of famotidine. b) The client diagnosed with COPD needs vital signs taken. c) The client requires discharge instructions. d) The client requires a sterile dressing change. 41. The pediatric community health nurse plans visits for the day. Which client will the nurse see first? a) A 10-year-old with a blood lead level of 9 µg/dL. b) An 8-year-old who is aggressive toward siblings when angry. c) A 6-year-old with elevated temperature, cough, and fine crackles. d) An infant who had pyloromyotomy 4 weeks ago. 42. The nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. Which client does the nurse assign to a nursing assistive personnel? a) Assist an elderly client with lunch. b) Administer famotidine to the client at 0800. c) Change a dressing for a postoperative client. d) Instruct a client about signs and symptoms of lithium toxicity. 43. The RN assesses clients for the day shift. The nursing team includes one RN, two LPNs, and four UAPs. The nurse determines that assignments are appropriate if which of the following patients is assigned to a UAP? a) A patient diagnosed with Crohn’s disease requiring a sterile dressing change. b) A patient diagnosed with chronic renal failure requiring intake and output. c) A patient diagnosed with full thickness burns requiring IV morphine prior to a dressing change. d) A patient diagnosed with cancer of the lung complaining of a headache. 44. A community health maternity nurse plans visits for the day. Which client should the nurse see first? a) A newborn who had an Apgar score of 8 and 9. b) A newborn with telangiectatic nevi. c) A newborn with pallor. d) A newborn with a blood glucose of 60 mg/dL. 45. Which client assignment on a maternity unit does the nursing assistive personnel question? a) Ambulate a client 24 hours after the birth of the child. b) Administer acetaminophen for pain to a client who has an episiotomy. c) Assist a client with morning care. d) Give the client pads for vaginal bleeding. 46. Which client should the nurse on the vascular unit assess first after receiving the shift report? a) The client with lymphedema whose ABG results are pH 7.33, PaO2 89, PaCO2 47, HCO3 25. b) The client with Raynaud’s phenomenon who has bluish cold upper extremities. c) The client with chronic venous insufficiency who has an ulcerated area on the right foot. d) The client receiving intravenous heparin infusion who has a PTT on 78. 47. After receiving the night shift’s report, the nurse plans assignments for the day on the Pediatric Unit. Which client will the nurse see first? a) A client diagnosed with leukemia reporting fatigue. b) A client diagnosed with Wilms’ tumor reporting thirst. c) A client diagnosed with hemophilia reporting joint pain. d) A client diagnosed with gastroesophageal reflux reporting abdominal pain. 48. A nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. Which client assigned to the LPN does the LPN question? a) An infant requiring a bath prior to discharge. b) An infant with a palpable olive-shaped mass in the epigastrium and frequent vomiting. c) An infant requiring eye drops instilled. d) An infant requiring a rectal temperature taken every 6 hours. 49. Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) a) Perform mouth care on the client with pneumonia. b) Apply oxygen via nasal cannula to the client. c) Empty the trashcans in the clients’ rooms. d) Take the empty blood bag back to the laboratory. e) Show the client how to ambulate on the walker. 50. The elderly client on a cardiac unit has a DNR order written. Which intervention should the nurse implement? a) Continue to care for the client’s needs as usual. b) Place notification of the DNR inside the client’s chart. c) Refer the client to a hospice organization. d) Limit visitors to two at a time, so as not to tire the client. 51. The charge nurse is checking the morning laboratory results for the clients. Which laboratory results requires notifying the client’s healthcare provider? a) The client with hypoparthyroidism who has a decreased serum calcium level. b) The client with Cushing’s disease who has a decreased urine cortisol level. c) The client with diabetes insipidus who has a low urine specific gravity. d) The client with hyperthyroidism who has an increased TSH level. 52. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? a) The client has purposeful movement when the nurse rubs the sternum. b) The client extends the upper and lower extremities in response to painful stimuli. c) The client is aimlessly thrashing in the bed when a noxious stimulus is applied. d) The client is able to squeeze the nurse’s hand on a verbal request. 53. A nursing team consists of an RN, two LPNs, and two nursing assistive personnel. It is most appropriate for the nurse to care for which client? a) A client with right-sided weakness requiring assistance with morning care. b) A client requiring administration of digoxin and furosemide via an NG tube. c) A client whose adult child is upset because the client is diagnosed with terminal cancer. d) A client 24 hours after a laminectomy with spinal fusion having difficulty voiding. 54. The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? a) Tell the LPN to notify the clinic healthcare provider (HCP). b) Instruct the LPN to assess the client for abnormal bleeding. c) Obtain a stat electrocardiogram on the client. d) Take no action because this INR is within the normal range. 55. The unlicensed assistive personnel (UAP) tells the clinic nurse that the male client in Room 1 is “really breathing hard and can’t seem to catch his breath.” Which instruction should the nurse give to the UAP? a) Put 4 mL oxygen on the client. b) Sit the client upright in a chair. c) Go with the nurse to the client’s room. d) Take the client’s vital signs. 56. The male client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? a) Request the client to urinate in a urinal. b) Assess the client’s pain. c) Increase the client’s oral fluid intake. d) Strain the client’s urine. 57. Which task should the nurse on the renal unit assign to the LPN? a) Insert an indwelling urinary catheter before surgery. b) Turn and reposition the client every 2 hours. c) Measure and record the urine in the bedside commode. d) Feed the client who choked on food during the last meal. 58. The nurse cares for the client diagnosed with quadriplegia who is on a ventilator. Which task can the nurse delegate to the nursing assistive personnel assigned to help with the client’s care? a) Suctioning of the tracheostomy. b) Evaluation for pressure ulcers. c) Management of the ventilator. d) Assisting with feeding the client. 59. The client who has had abdominal surgery is complaining of pain and tells the nurse, “I felt something pop in my stomach.” Which intervention should the nurse implement first? a) Check the client’s apical pulse and blood pressure. b) Assess the client’s surgical wound site. c) Determine the client’s pain on a 1 to 10 pain scale. d) Administer pain medication intravenously. 60. Which client should the nurse on the endocrinology unit assess first? a) The client with hypothyroidism whose vital signs are T 94.2°F, HR 48, RR 14, BP 90/68. b) The client with hypoparathyroidism who has a positive Chvostek’s sign. c) The client who is 1 day postoperative thyroidectomy who is hoarse. d) The client with diabetes insipidus who is drinking large amounts of water. 61. The nurse is assessing clients on a respiratory unit. Which client should be the nurse’s first priority? a) The client diagnosed with bronchiectasis who has clubbing of the fingernails. b) The client diagnosed with byssinosis who reports chest tightness. c) The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%. d) The client diagnosed with pneumoconiosis who has shortness of breath. 62. Which client should the medical unit nurse assess first after receiving the shift report? a) The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. b) The 25-year-old client diagnosed with influenza who is febrile and has a headache. c) The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. d) The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose. 63. The nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? a) The UAP places the gait belt around the client’s waist prior to ambulating. b) The UAP places the client on the abdomen with the client’s head to the side. c) The UAP places her hand under the client’s right axilla to help the client move up in bed. d) The UAP praises the client for performing activities of daily living independently. 64. The nurse and UAP are caring for a group of clients. Which nursing intervention should the nurse perform? a) Measure the client’s output from the indwelling catheter. b) Record the client’s intake and output on the I&O sheet. c) Instruct the client on appropriate fluid restrictions. d) Provide water for a client diagnosed with acute polynephritis. 65. The nurse and UAP are caring for clients on the endocrinology unit. Which task should NOT be delegated to the UAP? a) Ambulate the client who had a unilateral adrenalectomy. b) Change the linens on the client with acute thyrotoxicosis who is diaphoretic. c) Bring ice-cold water to the client diagnosed with diabetes insipidus. d) Take the vital signs of a client who has just returned from the post-anesthesia care unit (PACU). 66. The nurse has just received the shift report. Which client should the nurse assess first? a) The client with Guillain-Barré syndrome who has ascending paralysis to the knees. b) The client with a C-6 spinal cord injury who has autonomic dysreflexia. c) The client with Parkinson’s disease who is experiencing “pill rolling.” d) The client with Huntington’s disease who has writhing, twisting movements of the face. 67. An RN has received report and assesses the clients on the unit. The RN assigns which client to the LPN? a) A client newly admitted with a diagnosis of myocardial infarction. b) A client with a diagnosis of heart failure who expresses frequent suicidal thoughts. c) A client diagnosed with full-thickness burns covering 40% of the body. d) A client diagnosed with COPD who requires ambulation twice during the evening. 68. The nurse has received the a.m. shift report. Which client should the nurse assess first? a) The client with peptic ulcer disease who is complaining of acute epigastric pain. b) The client with acute gastroenteritis who is upset and wants to go home. c) The client with inflammatory bowel disease who is receiving total parental nutrition. d) The client with hepatitis B who is complaining and who is jaundiced and anorexic. 69. The nurse cares for six clients on a medical-surgical unit. Which client assigned to the nurse has the highest risk for sudden changes in homeostasis? a) The client who had a herniorrhaphy 12 hours ago with vital signs taken every 4 hours. b) The client with an infected leg ulcer who receives IV antibiotics every other hour. c) The client admitted earlier today after being in an MVA with vital signs taken every hour. d) The client who is up and ambulating 2 days after a transurethral resection for BPH. 70. The RN has received an assignment for the night shift. Which task is appropriate for the nurse to delegate to a nursing assistive personnel with 20 years of experience? a) Assess the breathing pattern of an asthmatic client. b) Monitor a client who is expectorating rust-colored sputum. c) Administer codeine to a postoperative client. d) Bathe a client prior to the scheduled 0600 surgery. 71. While in the ED, a client experiences chest discomfort and pain radiating down the arm. The client’s cardiac monitor shows two runs of ventricular tachycardia. The client is admitted to the medical-surgical unit from the ED. Which staff member is assigned to this client? a) Nursing assistive personnel b) Certified nursing assistant c) LPN d) RN 72. The nurse is admitting a patient diagnosed with pneumonia. Which order should be implemented first? a) 1,000 mL normal saline at 125 mL/hour. b) Obtain sputum for Gram stain and culture. c) Ceftriaxone (Rocephin) 1,000 mg IVPB every 12 hours. d) Ultrasonic nebulization treatment every 6 hours. 73. The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? a) Altered nutrition. b) Self-care deficit. c) Impaired body image. d) Fluid and electrolyte imbalance. 74. The 19-year-old client is in the rehabilitation unit following a traumatic brain injury. Which intervention should the nurse delegate to the UAP? (Select all that apply.) a) Make safety rounds hourly. b) Refer the client to a college and career counselor. c) Assist the client with meals. d) Clamp and unclamp the indwelling catheter every 2 hours. e) Discuss discharge placement with the parents. 75. Which client should the nurse assess first after receiving the night shift assessment? a) The client with Barrett’s esophagus who has dysphagia and pyrosis. b) The client with proctitis who has tenesmus and passage of mucus through the rectum. c) The client with liver failure who is jaundiced and has ascites. d) The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr. 76. The nursing team caring for clients on the pediatric unit consists of one RN, two LPNs, and three nursing assistive personnel. Which client does the RN assign to the nursing assistive personnel? a) A child who needs help socializing with other children. b) A child requiring an 0800 insulin injection c) A child with a blood lead level of 70µg/dL requiring calcium disodium edentate. d) A child reporting abdominal tenderness in the right lower quadrant. 77. The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client’s priority nursing diagnosis? a) Activity intolerance. b) Altered coping. c) Impaired gas exchange. d) Self-care deficit. 78. The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed orientation? a) The client with ALS on a ventilator who is dying and whose family is with them at the bedside. b) The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). c) The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. d) The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours. 79. Which nursing diagnosis is a priority for the client who had undergone a TURP? a) Potential for sexual dysfunction. b) Potential for altered urinary elimination. c) Potential for infection. d) Potential for hemorrhage. 80. The charge nurse is making shift assignments to the surgical staff, which consists of two nurse, two LPNs, and two UAPs. Which assignment would be most appropriate for the charge nurse to make? a) Instruct the nurse to administer all PRN medications. b) Instruct the UAP to clean the recently vacated room. c) Assign the LPN to change the client’s ileal conduit bag. d) Request the LPN to complete the admission for a new client. 81. The nursing team caring for clients on the pediatric unit consists of one RN, one LPN, and two nursing assistive personnel. Which client does the RN assign to the LPN? a) The child admitted with vomiting, weight loss, and abdominal pain. b) The child admitted with decreased hemoglobin and hematocrit reporting fatigue. c) The child diagnosed with a UTI who requires discharge instructions. d) The infant requiring antibiotic ointment on the circumcision site. 82. Which task is most appropriate for the nurse to delegate/assign when caring for clients on a surgical unit? a) Instruct the licensed practical nurse (LPN) to feed the client who is 1 day postoperative unilateral thyroidectomy. b) Ask another nurse to administer an IVP pain medication to a postoperative client in severe pain. c) Request the UAP to check the client whose vital signs are AP 112, RR 26, BP 92/58. d) Instruct the licensed practical nurse (LPN) to obtain the pre-transfusion assessment on a postoperative client. 83. Which activity is inappropriate for the LPN to perform? a) Indwelling urinary catheterization. b) Reading the telemetry monitor. c) Emptying a closed-wound drainage system. d) Applying a hypothermia blanket. 84. The nurse is caring for a client diagnosed with Alzheimer’s disease. Which nursing tasks should not be delegated to the UAP? (Select all that apply.) a) Check the client’s skin under the restraints. b) Administer the client’s antipsychotic medication. c) Perform the client’s morning hygiene care. d) Ambulate the client to the bathroom. e) Obtain the client’s routine vital signs. 85. The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? a) The client with an inguinal hernia repair who has a urine output of 160 mL in 4 hours. b) The client with an emergency appendectomy who was transferred from PACU. c) The client who is 4 hours postoperative abdominal surgery who has flatulence. d) The client who is 6 hours post-procedure colonoscopy and is being discharged. 86. The charge nurse makes intensive care staff assignments for the shift. Which client is appropriate for the nurse reassigned from the medical-surgical unit? a) The client who is 3 days post-myocardial infarction waiting to transfer to the step-down unit. b) The client diagnosed with cardiogenic shock. c) The client who just had an arterial line placed. d) The client who underwent open-heart surgery 10 hours ago. 87. The clinic nurse is assessing a client who is complaining of right leg calf pain. The right calf is edematous and warm to the touch. Which intervention should the nurse implement first? a) Notify the clinic HCP immediately. b) Ask the client how long the leg has been hurting. c) Complete a neurovascular assessment on the leg. d) Place the client’s right leg on two pillows. 88. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? a) The client diagnosed with polycystic kidney disease who has a B/P 170/100. b) The client diagnosed with bladder cancer who has gross painless hematuria. c) The client diagnosed with renal calculi who thinks he passed a stone. d) The client with acute pyelonephritis who has nausea/vomiting and is dehydrated. 89. The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? a) Feed the client who has an IV in both forearms. b) Assess the client diagnosed with stage IV heart failure. c) Discharge the client who had a cardiac catheterization. d) Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin). 90. The client needs all of these activities completed by the nurse. Which activity should the nurse complete first? a) Perform passive range of motion exercises on the client. b) Medicate the client for pain. c) Transfer the client from the bed to the chair. d) Wash the client’s hair. 91. The charge nurse delegates care for the shift to the team members. Which duty can the nurse safely and appropriately delegate to an LPN? a) Perform a venipuncture and start an IV drip. b) Perform a dressing change with sterile procedure. c) Perform vital signs and hang a unit of packed red blood cells (PRBCs). d) Perform a urethral catheterization on a post-TURP client. 92. The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first? a) The client who has a paralytic ileus and has absent bowel b) sounds. c) The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen. d) The client who is 6 hours postoperative and has an abdominal wound dehiscence. e) The client who had a liver transplant and is being transferred to the rehabilitation unit. 93. The nursing team caring for clients on the pediatric unit consists of two RNs, two LPNs, and two nursing assistive personnel. Which client does the RN assign to the LPN? a) A child admitted with asthma. b) A child in a balanced suspension traction for a fractured left femur. c) A child admitted for intestinal bleeding. d) A child admitted for taking a grandparent’s hypertensive medication. 94. The nursing team caring for clients on the pediatric unit consists of two RNs, one LPN, and two nursing assistive personnel. The nurse considers the assignment appropriate if the LPN is required to complete which task? a) Obtain vital signs for the client immediately after ECT. b) Assist the client with bathing and feeding. c) Administer a tube feeding for the client with dysphagia. d) Discharge the client diagnosed with multiple sclerosis. 95. The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first? a) Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn’s disease. b) Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia. c) Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease. d) Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery. 96. The client with open surgery of the kidney as an AP 118 and BP 88/58. Which intervention should the nurse implement first? a) Obtain the client’s pulse oximeter reading. b) Check the client’s last hemoglobin and hematocrit. c) Monitor the client’s urine output. d) Notify the client’s surgeon immediately. 97. The ICU nurse and UAP are caring for a client with right-sided paralysis secondary to a CVA. Which action by the UAP requires the nurse to intervene? a) The UAP performs passive range-of-motion (ROM) exercises for the client. b) The UAP places the client on the abdomen with the head to the side. c) The UAP uses a lift sheet when moving the client up in bed. d) The UAP praises the client for attempting to feed him- or herself. 98. The clinic nurse is caring for a 10-year-old client diagnosed with diabetes mellitus type 2. Which client problem is priority? a) Risk for low self-esteem. b) Hypoglycemia. c) Risk for loss of body part. d) Altered nutrition, excessive intake. 99. The client is admitted to the ED with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? a) Maintain sterile environment when caring for the client. b) Insert two large-bore intravenous access routes. c) Administer intravenous antibiotic therapy. d) Assess the client’s pain level on a 1 to 10 pain scale. 100. The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first? a) The client with a right total knee replacement who wants to be removed from the continuous passive motion (CPM) machine. b) The client diagnosed with chronic low back pain who is crying and upset about being discharged home. c) The client who has full-thickness burns who needs to be medicated before being taken to whirlpool. d) The client who is 1 week postoperative for right total hip replacement (THR) who has a temperature of 100.4°F. 101. The nurse manager in the medical-surgical outpatient clinic is making assignments. Which task is most appropriate to delegate/assign to the UAP/LPN? a) Ask the LPN to administer the flu vaccine to the client. b) Tell the UAP to call the pharmacist to refill a prescription. c) Request the LPN to obtain the height and weight of the client. d) Instruct the UAP to empty the trashcans in the clients’ rooms. 102. The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants immediate intervention by the nurse? a) “My legs start to hurt when I walk to check my mail.” b) “My legs were so cold I had to put a heating pad on them.” c) “I hang my legs off the side of my bed when I sleep.” d) “I noticed that the hair on my feet and up my leg is gone.” 103. The nurse in the outpatient clinic is working with a UAP. Which tasks are most appropriate for the nurse to delegate to the UAP? (Select all that apply.) a) Take the client to the examination room and take the vital signs. b) Weigh the client and document the weight in the client’s chart. c) Clean the room and set it up for the next client. d) Discuss the prescriptions prescribed by the healthcare provider. e) Call the pharmacy to authorize a refill on a client’s prescription. 104. The nursing team caring for clients on the pediatric unit consists of two RNs, two LPNs, and two nursing assistive personnel. The nurse considers the assignment appropriate if the LPN is required to complete which task? a) Perform a sterile dressing change. b) Obtain vital signs. c) Stock supplies of syringes and dressings. d) Transfer a stable client to x-ray. 105. The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the UAP? a) Tell the UAP to check the amount, color, and consistency of the client’s urine output. b) Instruct the UAP to strain the client’s urine and place any sediment in a sterile container. c) Request the UAP to transcribe the client’s healthcare provider’s orders. d) Ask the UAP to take the client’s post-procedural vital signs. 106. A community health nurse plans visits for the day. Which of the following patients should the nurse see first? a) A 5-year-old male experiencing hyperactivity and impulsivity for two weeks. b) A 13-year-old female truant from school for three days. c) A 13-year-old female vomiting every day for the last three months because she wants to lose weight for the summer. d) A 25-year-old male who drinks alcohol every day and is unable to control the amount of alcohol he ingests. 107. The nurse is working on an orthopedic unit. Which client should the nurse assess first? a) The client who is 1 week postoperative for L3–L4 laminectomy who is complaining of numbness and tingling of the feet. b) The client who is 2 weeks postoperative open reduction and external fixation (ORIF) of the right hip who is complaining of pain when ambulating. c) The client who is 10 days postoperative for left total knee replacement (TKR) who is refusing to use the continuous passive motion (CPM) machine. d) The client who is being admitted to the rehabilitation unit from the orthopedic surgical unit after an MVA. 108. Ten clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the ED. Which client should the nurse see first? a) A client with ecchymosis and lacerations to the facial area. b) A client reporting shortness of breath and pressure in the chest. c) A client with a blood pressure of 90/60 and apical pulse of 120 bpm. (indicate shock) d) A client reporting dizziness and nervousness. 109. Which client warrants immediate intervention from the nurse on the medical unit? a) The client diagnosed with dyspepsia who has eructation and bloating. b) The client diagnosed with pancreatitis who has steatorrhea and a fever. c) The client with diverticulitis who has left lower quadrant pain and fever. d) The client with Crohn’s disease who has right lower abdominal pain and diarrhea. 110. The nurse and a UAP are caring for clients on a vascular unit. Which task should the nurse delegate to the UAP? a) Apply bilateral sequential compression devices to the client with deep vein thrombosis. b) Accompany the client with thromboangiitis obliterans outside to smoke a cigarette. c) Elevate the leg of the client who is one day postoperative femoral-popliteal bypass. d) Perform Doppler studies on the client with right upper extremity lymphedema. 111. The nurse is preparing to teach the male client how to irrigate his sigmoid colostomy. Which intervention should the nurse implement first? a) Demonstrate the procedure on a model. b) Provide the client with written instructions. c) Ask the client whether he has any questions. d) Show the client all of the equipment needed. 112. Which task should the nurse delegate to the UAP? a) Request the UAP read the PPD result administered to the client 72 hours ago. b) Tell the UAP to apply an ice pack to the client who slipped and has a sprained right ankle. c) Ask the UAP to obtain a urine specimen for the client having a urine drug screening. d) Instruct the UAP to complete the incident report for the nurse who had a “dirty needle stick.” 113. A 12-year-old boy was riding his bike to school when he fell. The boy goes to the school nurse and says “I hurt my leg when I fell off my bike.” What is the first action the nurse should take? a) Immobilize the affected limb b) Ask the boy to explain what happened c) Put him in semi-fowlers position d) Check the affected limb 114. The client with hypothyroidism and a diagnosis of myxedema coma is admitted to the critical care unit. Which assessment data warrants immediate intervention by the nurse? a) The client’s blood glucose level is 74 mg/dL. b) The client’s temperature is 96.2°F; AP, 54; R, 12; and BP, 90/58. c) The client’s ABG values are pH 7.33; PaO2 78; PaCO2 48; HCO3 25. d) The client is lethargic and sleeps all the time. 115. The client comes to the clinic reporting pain and burning on urination. What should the nurse implement first? a) Request the client give a midstream urine specimen. b) Assess and document the client’s vital signs. c) Determine whether the client has seen any blood in the urine. d) Ask the client whether she wipes front to back after a bowel movement. 116. The nurse is administering medications on a neurological unit. Which medication should the nurse administer first? a) The morning medications to the client scheduled for physical therapy. b) The narcotic pain medication to a client with increased intracranial pressure. c) The anticonvulsant gabapentin (Neurontin) to the client with restless legs syndrome. d) The osmotic diuretic to the client with a closed head injury. 117. The nurse is caring for a client diagnosed with a full-thickness burn over the right lower extremity. Which task should the nurse delegate to the UAP? a) Instruct the UAP to check the client’s right dorsalis pedal pulse. b) Ask the UAP to cleanse the client’s dentures and place in the container. c) Request the UAP to perform passive range-of-motion (ROM) exercises. d) Tell the UAP to keep the client’s right leg in the dependent position. 118. The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? a) The client’s hemoglobin/hematocrit is 11.4/32. b) The client’s abdomen is soft to touch and non-tender. c) The client’s vital signs are T 99, AP 114, RR 18, BP 88/60. d) The client’s nasogastric tube has coffee ground drainage. 119. Which client should the endocrinology nurse assess first after receiving the shift report? a) The client diagnosed with Grave’s disease who has exophthalmos and bruits over the thyroid gland. b) The client who is 1 day postoperative transsphenoidal hypophysectomy who has clear drainage from the nose. c) The client with hyperparathyroidism who is complaining of weakness, loss of appetite, and constipation. d) The client with Addison’s disease who has orthostatic hypotension, nausea, and vomiting. 120. The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate? a) Provide indwelling catheter care to a client on bed rest. b) Evaluate the client’s 8-hour intake and output. c) Give a bath to the client who is third-spacing. d) Administer a cation-exchange resin enema to a client. 121. The nurse has received the morning shift report on a surgical unit. Which client should the nurse assess first? a) The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants. b) The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset. c) The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen. d) The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10. 122. The nurse is caring for an 84-year-old male client diagnosed with benign prostatic hypertrophy (BPH). The client has undergone a TURP and is complaining of bladder spasms. Which intervention should the nurse implement first? a) Administer an antispasmodic medication for bladder spasms. b) Assess the client’s three-way urinary catheter for patency. c) Calculate the client’s urinary output. d) Palpate the client’s abdomen for bladder distention. 123. Which client should the charge nurse assess first after receiving the change-of-shift report? a) The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12. b) The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. c) The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. d) The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%. 124. The charge nurse has completed report. Which client should be seen first? a) The client diagnosed with ulcerative colitis who had five loose stools the previous shift. b) The elderly client admitted from another facility who is refusing to be seen by the nurse. c) The client with hemorrhoids who had spotting of bright red blood on the toilet tissue. d) The client with intractable vomiting who has tented skin turgor and dry mucous membranes. 125. Which behavior by the UAP warrants intervention by the long-term care nurse? a) The UAP is giving the client with a gastrostomy tube a glass of water. b) The UAP is ambulating the client outside using a safety belt. c) The UAP is assisting the client with putting a jigsaw puzzle together. d) The UAP is giving a back rub to the client who is on bed rest. 126. The nurse is preparing to administer morning medications. Which medication should the nurse administer first? a) The levothyroxine (Synthroid), a thyroid hormone, to a client diagnosed with hypothyroidism. b) The Humulin N insulin, a pancreatic hormone, to a client diagnosed with type 2 diabetes. c) The prednisone, a glucocorticoid, to a client diagnosed with Addison’s disease. d) The tiotropium (Spiriva) inhaler, a bronchodilator, to a client diagnosed with chronic asthma. 127. The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first? a) The client diagnosed with angina who is reporting chest pain. b) The client diagnosed with CHF who has bilateral 4+ peripheral edema. c) The client diagnosed with endocarditis who has a temperature of 100°F. d) The client diagnosed with aortic valve stenosis who has syncope. 128. The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? a) The client diagnosed with mitral valve stenosis. b) The client diagnosed with asymptomatic sinus bradycardia. c) The client diagnosed with fulminant pulmonary edema. (happens all of a sudden, intense) d) The client diagnosed with acute atrial fibrillation. 129. Which task should the nurse in a long-term care facility delegate to the UAP? a) Assist the resident up in a wheelchair for meals. b) Assess the incontinent client’s perianal area. c) Discuss requirements with the client for going out on a pass. d) Explain how to care for the client’s colostomy to the family. 130. Which task is most appropriate for the nurse on the renal unit to delegate to the UAP? a) Escort the client with acute polynephritis to the radiology department for a CT scan. b) Obtain a sterile urine specimen for the client to rule out (R/O) a urinary tract infection. c) Hang the bag of D5W for the client diagnosed with post–streptococcal glomerulonephritis. d) Provide discharge instructions for the client diagnosed for nephrotic syndrome. 131. The nurse is preparing to administer medications for clients on a medical unit. The client diagnosed with hypothyroidism is complaining of being hot all the time, feeling palpitations, and being jittery. Which intervention should the nurse implement first? a) Check the client’s serum thyroid levels. b) Assess the client for diarrhea. c) Hold the client’s thyroid medication. d) Document the finding in the chart. 132. Which priority intervention should the nurse implement for the client diagnosed with SIADH? a) Position the client’s head of bed with no more than 10 degrees of elevation. b) Turn and reposition the client every 2 hours while on bed rest. c) Provide frequent oral hygiene every 2 hours for the client. d) Maintain the prescribed daily fluid restriction. 133. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? a) The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO2 44, HCO3 30. b) The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10. c) The client who is 12 hours postoperative abdominal surgery and has dark green bile draining in the nasogastric tube. d) The client who is 2 days postoperative for hiatal hernia repair and is complaining of feeling constipated. 134. The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? a) Assess the client’s pulse oximeter reading. b) Notify the Rapid Response Team. c) Place the client in the Trendelenburg position. d) Check the client’s surgical dressing. 135. Which intervention should the nurse implement first for the client diagnosed with urinary incontinence? a) Administer oxybutynin, an anticholinergic agent. b) Ensure the client does not sit or lie in the urine. c) Palpate the bladder after an incontinent episode. d) Instruct the client to go to the bathroom every 2 hours. 136. The client is 8 hours postoperative spinal surgery. Which priority intervention should the nurse implement? a) Evaluate how much pain medication the client is using via the patient-controlled analgesia (PCA) pump. b) Logroll the client with three staff members when turning the client side to side. c) Assist the client to ambulate to the bathroom using an elevated commode seat. d) Place pillows under the thighs of each leg when the client is in supine position. 137. A 12-year-old boy was riding his bike to school when he fell. The school nurse was called and found him alert, conscious, but in severe pain with a possible fracture to the right tibia. What is the first action the nurse should take? a) Immobilize the affected limb b) Assess the surroundings to determine the cause of the fall c) Put the patient in semi-fowlers position to facilitate breathing d) Check the pedal pulse 138. The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse? a) The client who has an INR of 2.8. b) The client who has a serum potassium level of 3.8 mEq/L. c) The client who has a serum digoxin level of 2.6 mg/dL. d) The client who has a glycosylated hemoglobin of 6%. Therapeutic serum digoxin level is 0.5-2mg/dL. 139. The nurse is caring for clients on the renal unit. Which task is more appropriate for the nurse to delegate to the UAP? a) Request the UAP to double-check a unit of blood that is being administered. b) Tell the UAP to change the surgical dressing on the client with a kidney transplant. c) Ask the UAP to transfer the client from the renal unit to the intensive care unit. d) Instruct the UAP to calculate the clients’ urinary intake and output. 140. The client is experiencing severe diarrhea and a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first? a) Notify the client’s healthcare provider. b) Assess the client for leg cramps. c) Place the client on cardiac telemetry. d) Prepare to administer intravenous potassium. 141. The LPN tells the nurse the client diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first? a) Assess the client’s neurological status. b) Notify the client’s healthcare provider. c) Request a STAT ammonia serum level. d) Tell the LPN to obtain the client’s vital signs. 142. The nurse is caring for clients in an ophthalmology clinic. Which client warrants intervention by the nurse? a) The client with cataracts who reports decreased vision and abnormal color perception. b) The client with a retinal detachment who reports a painless loss of peripheral vision. c) The client with an external hordeolum who reports reddened tender area under eye. d) The client with primary open angle glaucoma who reports excruciating eye pain. 143. A nurse is teaching a patient with coronary artery disease about dietary measures to follow. The patient expresses frustration in learning the information. What would the nurse do initially? a) Identify the cause of the frustration. b) Notify the physician. c) Continue with the teaching. d) Tell the patient that the diet must be followed. 144. The nursing is caring for an elderly female client who has an indwelling catheter. Which data warrants notifying the healthcare provider? a) The client’s vital signs are T 98, AP 90, RR 16, BP 142/88. b) The client has had a change in her mental status. c) The client’s urine is cloudy with sediment. d) The client has no discomfort or pain. 145. The nurse is working in a community health clinic. Which task should the nurse delegate to the UAP? a) Instruct the UAP to take the client’s history. b) Request the UAP to document the client’s complaints. c) Ask the UAP to obtain the client’s weight and height. d) Tell the UAP to complete the client’s follow-up care. 146. The client in a multiple car crash dies in the emergency department. Which priority intervention should the ED nurse implement when addressing the needs of the client’s family? a) Ask if the client wanted to be a tissue donor. b) Give the family the client’s personal belongings. c) Determine which funeral home should be contacted. d) Escort the family to a private room to grieve. 147. The charge nurse on the rehabilitation unit is assigning/delegating tasks to the UAP and LPN. Which task is most appropriate for the nurse to delegate/assign? a) Tell the UAP to elevate client’s residual limb above the heart. b) Instruct the LPN to give the diabetic clients their HS snacks. c) Request the UAP to insert an indwelling urinary catheter. d) Ask the LPN to assess the client who may have herpes zoster. 148. The nurse on the endocrinology unit is caring for clients, assisted by a UAP. Which task is most appropriate to delegate to the UAP? a) Feed the client who is 1 day postoperative transsphenoidal hypophysectomy. b) Obtain a urine specimen for the client diagnosed with diabetes insipidus. c) Take the vital signs for the client diagnosed with myxedema coma. d) Assess the pulse oximeter reading of the client with an Addisonian crisis. 149. The nurse is caring for clients in the emergency department. Which client should the nurse assess first? a) The client with an epidural hematoma. b) The client who had a seizure who is in the postictal state. c) The client diagnosed with R/O encephalitis who has a headache. d) The client with multiple sclerosis who has scanning speech. 150. The nursing team includes three RNs and one LPN. The assignments are appropriate if the LPN is assigned which client? a) An 18-month-old 1 day post cleft palate repair. b) A 3-year-old child 1 day post umbilical hernia repair. c) A 6-year-old child newly admitted with nephrotic syndrome. d) A 10-year-old girl 1 day post Harrington rod insertion. 151. The RN instructs the nursing assistive personnel to administer an enteral feeding through a nasogastric tube. Which action will the RN take next? a) Instruct the NAP to infuse the tube feeding slowly. b) Place the client in high Fowler’s position. c) Assess the pH of the gastric aspirate. d) Instruct the NAP to obtain the client’s weight. 152. The RN evaluates assignments on an adult acute-care unit. The RN determines that assignments are appropriate if nursing assistive personnel performs which task? a) Encourages a client to practice the postoperative exercises taught by the RN. b) Irrigates the nasogastric tube of a client receiving a tube feeding for 12 hours during the day. c) Performs a sterile dressing change for a client with a pressure ulcer. d) Determines the effectiveness of the restraints for a client in a halo vest device. 153. The nurse is working on an endocrinology unit. Which client should the nurse assess first? a) The client diagnosed with diabetes insipidus who has polyuria and polydipsia. b) The client who is 1 day postoperative thyroidectomy who has neck edema. c) The client who has hypoparathyroidism who has painful muscle cramps and irritability. d) The client diagnosed with Addison’s who has weakness, fatigue, and anorexia. 154. The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation? a) The client with a cystectomy who had a creation of an ileal conduit. b) The client on continuous hemodialysis who is awaiting a kidney transplant. c) The client with renal trauma secondary to a motor vehicle accident. d) The client who has had abdominal surgery and whose wound has eviscerated. 155. The client with a C-6 spinal cord injury comes to the emergency department complaining of a throbbing headache and has a BP of 200/120. Which intervention should the nurse implement first? a) Place the client on a telemetry unit. b) Complete a neurological assessment. c) Insert an indwelling urinary catheter. (develop neurogenic bladder, increased BP) d) Request a STAT CT scan on the head. 156. Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? a) Evaluating the patient’s complaint of chest pain. b) Monitoring laboratory values for changes in oxygenation. c) Assessing for symptoms of respiratory failure. d) Administer Heparin 5000 units SQ. 157. The nurse is developing a nursing care plan for the client diagnosed with chronic kidney disease. Which nursing problem should be addressed first? a) Self-care deficit. b) Knowledge deficit. c) Chronic pain. d) Excess fluid volume. 158. The nurse and LPN have been assigned to care for clients on the neurology unit. Which nursing task is most appropriate to assign to the LPN? a) Administer the adrenocorticotropic hormone to the client with multiple sclerosis. b) Take the vital signs for the client who is experiencing status epilepticus. c) Assist the client with Parkinson’s disease to ambulate to the bathroom. d) Assess the client newly admitted who has pneumonia and restless legs syndrome. 159. An elderly patient was just admitted to the nursing unit and displays severe dehydration. The nurse is planning care for the patient. Which task is appropriate to delegate to the nursing assistant? a) Obtain fluid history. b) Check skin turgor. c) Monitor for confusion. d) Record urine output. 160. A 36-year-old woman who fractured her femur in an MVA is placed in balanced suspension skeletal traction. The patient reports "terrible" pain in the affected limb. Initially, the nurse should: a) Determine that the weights and ropes from traction are in line and hanging freely. b) Ask the patient for more information on the location and characteristics of pain. c) Check the splints and attachments for proper position. d) Explain that pain is common with this type of injury. 161. The mother of a 10 y/o boy with Type 1 DM calls the MD office to discuss the child's FS measurement. The child is on a regimen of NPH and regular insulin before breakfast and dinner. The past 2 mornings his blood sugars were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to: a) Continue with the current medication regiment. b) Check his blood sugar during the night. c) Give his NPH later in the evening. d) Serve his bedtime snack earlier in the evening. 162. The charge nurse on the acute care rehabilitation unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse? a) The client with a full-thickness burn who is refusing to go to therapy. b) The client with osteomyelitis who has bone pain and a fever. c) The client with fractured tibia who has deep, unrelenting pain. d) The client with low back pain radiating down the left leg. 163. The client ambulating down the orthopedic hallway unassisted fell to the floor. Which action should the nurse implement first? a) Complete an adverse occurrence report. b) Notify the clinical manager on the unit. c) Determine whether the client has any injuries. d) Ask why the client was in the hall alone. 164. The nurse plans care for a female patient who has had fever, vomiting and diarrhea. The nursing diagnosis of "fluid volume deficit" is determined. Which of the following changes in lab values would indicate an improvement in the patient's condition? a) Urine specific gravity 1.015; HCT 38% b) Urine specific gravity 1.035; HCT 48% c) Urine specific gravity 1.015; HCT 46% d) Urine specific gravity 1.035; HCT 33% 165. The MD orders furosemide and spironalactone for a patient. Before administering the medications, the nurse notes that the potassium level is 3.2 mEq/L. In addition to notifying the MD, what other nursing action is expected? a) Hold the furosemide and spironolactone. b) Administer the spironolactone only. c) Administer the furosemide only. d) Administer both medications and re-check the potassium level. 166. Staffing for the shift consists of three registered nurses (RN) and one licensed practical nurse (LPN). Which assignment is not appropriate for the LPN? a) A 55-year-old male with COPD scheduled for discharge. b) A 42-year-old female in bucks traction for pelvic fracture. c) A 40-year-old female newly diagnosed with seizures. d) A 38-year-old male scheduled for an MRI in one hour. 167. The nurse obtains a diet history from a pregnant 16-year-old girl. The girl tells the nurse that her typical daily diet includes cereal & milk; pizza & soda; and a cheeseburger, milkshake, fries & salad. The most accurate nursing diagnosis is: a) Altered nutrition: more than body requirements related to high fat intake. b) Knowledge deficit: nutrition in pregnancy. c) Altered nutrition: less than body requirements related to increased demands of pregnancy. d) Risk for injury: fetal malnutrition. 168. Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism? a) Assess the client’s bilateral breath sounds. b) Encourage the client to cough and deep breathe. c) Administer oxygen via nasal cannula. d) Prepare to administer intravenous heparin therapy. 169. The UAP tells the nurse the client who had a thyroidectomy has a T 104° F, P 128, RR 26, BP 164/88. Which intervention should the nurse implement first? a) Prepare to administer the beta-adrenergic blocker propranolol (Inderal). b) Notify the healthcare provider immediately. c) Assess the client’s vital signs and surgical dressing. d) Administer acetaminophen (Tylenol) PO STAT. Wound infection 170. The client is 1 week postoperative for right below-the-knee amputation secondary to arterial occlusive disease. The nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first? a) Assess for paresthesia and paralysis. b) Utilize the Doppler device to auscultate the pulse. c) Place the client’s leg in the dependent position. d) Wrap the client’s left leg in a warm blanket. 171. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? a) Call a Code Blue immediately. b) Check the client’s telemetry leads. c) Find the nurse to check the client. d) Remove the telemetry monitor. 172. A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Pre-operatively, which of the following goals is most important for the nurse to include on the patient's plan of care? a) Pain relief b) Emotional support c) Respiratory therapy d) Fluid replacement 173. The hospice nurse is writing a care plan for a client diagnosed with type 2 diabetes mellitus who has peripheral neuropathy. Which client problem has priority for the client? a) Alteration in comfort. b) Altered glucose metabolism c) Anticipatory grieving. d) Spiritual distress. 174. The nurse and the UAP enter the client’s room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first? a) Ask the UAP to check whether the client is asleep. b) Tell the UAP to perform cardiac compressions. c) Instruct the UAP to get the crash cart. d) Request the UAP to put the client in a recumbent position. 175. The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement first? a) Administer oxygen 4 L/min via nasal cannula. b) Encourage the client to take deep breaths. c) Administer intravenous sodium bicarbonate. d) Assess the client’s respiratory status. 176. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? a) A client with a white blood cell count of 14,000 mm3 and a temperature of 38.4°C. b) A client scheduled for physical therapy for the first crutch-walking session. c) A postoperative client who has just received an opioid pain medication. d) A client who is ambulatory demonstrating steady gait. 177. The home health nurse is scheduling visits for the day. Which client should the nurse visit first? a) The client with an L-4 SCI who is complaining of a severe, pounding headache. b) The client with amyotrophic lateral sclerosis (ALS) who is depressed and wants to die. c) The client with Parkinson’s disease who is walking with a short, shuffling gait. d) The client with a C-5 SCI who reports redness and drainage at the Halo vest sites. 178. The nurse plans care for a 14-year-old girl admitted with an eating disorder. On admission, the girl weighs 82 lbs and is 5'4". Lab tests indicate severe hypokalemia, anemia and dehydration. The nurse should give which nursing diagnosis priority? a) Body image disturbance related to weight loss. b) Self esteem disturbance related to feelings of inadequacy. c) Altered nutrition: less than body requirements. d) Risk for decreased cardiac output related to potential dysrhythmia. 179. Which interventions should the nurse delegate to the UAP when caring for a client who is 2 days postoperative open surgery of the kidney? Select all that apply. a) Explain the procedure for using the patient-controlled analgesia (PCA) pump. b) Check the client’s flank surgical dressing for drainage. c) Take and record the client’s vital signs and pulse oximeter reading. d) Empty the client’s indwelling catheter bag at the end of the shift. e) Assist the client to ambulate in the hallway three to four times a day. 180. Staffing on a nursing unit consists of an RN with six months of experience, an LPN with 10 years of experience, and a nursing assistant with two years of experience. Which patient should be assigned to the RN? a) A patient who is 1 day post-op after open reduction internal fixation of the right arm. b) A patient who requires a transfusion of packed red blood cells (PRBCs). c) A patient who has contractures and hemiparesis from a stroke. d) A patient who is admitted with fatigue and exhaustion due to chemotherapy. 181. The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN? a) The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. b) The client diagnosed with pneumonia whose pulse oximeter reading is 90%. c) The client with acute bronchitis who has a chronic clear mucous cough and low fever. d) The client with reactive airway disease who has bilateral wheezing. 182. The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? a) Place sterile normal saline gauze on the eviscerated area. b) Reinforce the abdominal dressing with an ABD pad. c) Assess the client’s abdominal bowel sounds. d) Place the client in the left lateral position. 183. The nurse and UAP are working in a family practice clinic. Which task should the nurse delegate to the UAP? a) Give the client sample medications for a urinary tract infection (UTI). b) Take the vital signs of a client scheduled for a physical examination. c) Show the client how to use a self-monitoring blood glucometer. d) Answer the telephone triage line and take messages from clients. 184. A child with a compound fracture of the left femur is being admitted to a pediatric unit. Which of the following actions is best for the nurse to take? a) Ask the nursing assistive personnel to obtain the child’s vital signs while the nurse obtains a history from the parents. b) Ask the LPN to assess the peripheral pulses of the child’s left leg while the nurse completes the admission forms. c) Ask the LPN to stay with the child and his parents while the nurse obtains phone orders from the physician. d) Ask the nursing assistive personnel to obtain equipment for the child’s care while the nurse talks with the child and his parents. 185. The charge nurse on the rehabilitation unit is making assignments for the day shift. Which assignment would be most appropriate for the LPN? a) Have the LPN call the HCP to obtain an order for a diet change. b) Instruct the LPN to complete the admission assessment. c) Ask the LPN to teach the client about a high-fiber diet. d) Request the LPN to obtain the intake and output for the clients. 186. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a) A postoperative client preparing for discharge with a new medication. b) A client requiring daily dressing changes of a recent surgical incision. c) A client with asthma who requested a breathing treatment during the previous shift. d) A client scheduled for a chest x-ray after insertion of a nasogastric tube. 187. The nurse is planning care for the client diagnosed with Parkinson’s disease. Which client problem is priority? a) Altered nutrition. b) Altered mobility. c) Altered elimination. d) Altered body image. 188. The UAP working in a long-term care facility notifies the nurse that the client diagnosed with CHF who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first? a) Have the family bring food from home for the client. b) Check to see what the client has eaten in the past 24 hours. c) Tell the client that a low-sodium diet is an important part of the diagnosis. d) Ask the dietician to discuss food preferences with the client. 189. The nurse employed in an emergency department is assigned to triage clients coming into the ED for treatment on the evening shift. The nurse should assign priority to which client? a) A client with chest pain who states that he just ate pizza that was made with a very spicy sauce. b) A client with a minor laceration on the index finger sustained while cutting an eggplant. c) A client who twisted her ankle when rollerblading and is requesting medication for pain. d) A client complaining of muscle aches, a headache, and history of seizures. 190. Which client should the charge nurse on the rehabilitation unit assess first after receiving the a.m. shift report? a) The client diagnosed with an open reduction and external fixation (ORIF) of the right hip who has a hemoglobin and hematocrit (H&H) of 8/24. b) The client diagnosed with rheumatoid arthritis who has a positive rheumatoid factor (RF). c) The client diagnosed with a Stage IV pressure ulcer who has a white blood cell (WBC) count of 14,000. d) The client diagnosed with systemic allergies on prednisone dose pack who has a glucose level of 189 mg/dL. 191. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? a) A client requiring a colostomy irrigation. b) A client receiving continuous tube feedings. c) A client who requires urine specimen collection. d) A client with difficulty swallowing food and fluids. 192. The nurse employed in a long-term care facility is planning assignments. The nurse needs to assign four clients and has an LPN and three UAPs. Which client would the nurse most appropriately assign to the LPN? a) A client who requires a bed bath. b) An older client requiring frequent ambulation. c) A client who requires hourly vital sign measurements. d) A client requiring abdominal wound irrigations and dressing changes every 3 hours. 193. The nurse is caring for a client diagnosed with congestive heart failure who is currently complaining of dyspnea. Which intervention should the nurse implement first? a) Administer furosemide (Lasix), a loop diuretic, IVP. b) Check the client for adventitious lung sounds. c) Ask the respiratory therapist to administer a treatment. d) Notify the healthcare provider. 194. The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis “altered tissue perfusion related to decreased circulatory volume.” Which intervention should the nurse implement first? a) Notify the laboratory to draw a type & crossmatch. b) Assess the client’s abdomen for tenderness. c) Insert an 18-gauge catheter and infuse lactated Ringer’s. d) Check the client’s pulse oximeter reading. 195. The nurse is caring for clients on an oncology unit. Which client should the nurse assess first? a) The client diagnosed with leukemia who is afebrile and has a white blood cell (WBC) count of 100,000 mm3 . b) The client who has undergone four rounds of chemotherapy and is nauseated. c) The client diagnosed with lung cancer who has absent breath sounds in the lower lobes. d) The client diagnosed with rule out (R/O) breast cancer who had a negative biopsy this a.m. 196. The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? a) The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. b) The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. c) The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. d) The client who has been turning on the call light frequently and stating her care has been neglected. 197. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? a) The cardiac glycoside to the client who has an apical pulse of 58. b) The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. c) The antidysrhythmic to the client in ventricular fibrillation. d) The calcium-channel blocker who has a blood pressure of 110/68. 198. The nurse in a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer’s disease. Which client problem is priority for this client? a) Inability to do activities of daily living. b) Increased risk for injury. c) Potential for constipation. d) Ineffective family coping. 199. Which client should the telemetry nurse assess first after receiving the a.m. shift report? a) The client diagnosed with deep vein thrombosis who has an edematous right calf. b) The client diagnosed with mitral valve stenosis who has heart palpitations. c) The client diagnosed with arterial occlusive disease who has intermittent claudication. d) The client diagnosed with congestive heart failure who has pink frothy sputum. 200. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? a) The 44-year-old client diagnosed with a myocardial infarction. b) The 65-year-old client admitted with unstable angina. c) The 75-year-old client scheduled for a cardiac catheterization. d) The 50-year-old client complaining of chest pain. 201. The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? a) Assess the client’s lung sounds. b) Check for any kinks in the tubing. c) Ask the client to take deep breaths. d) Turn the client from side to side. 202. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? a) The UAP is instructed to bathe the client who is on telemetry. b) The UAP is requested to obtain a bedside glucometer reading. c) The UAP is asked to assist with a portable chest x-ray. d) The UAP is told to feed a client who is dysphagic. 203. Which client warrants immediate intervention by the nurse? a) The client diagnosed with pericarditis who has chest pain with inspiration. b) The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. c) The client diagnosed with Marfan syndrome who has pectus excavatum. d) The client diagnosed with atherosclerosis who has slurred speech and drooling. 204. Which medication should the nurse administer first after receiving the morning shift report? a) The IVPB antibiotic to the client with endocarditis admitted at 0530 today. b) The antiplatelet medication to the client who had a myocardial infarction. c) The coronary vasodilator patch to the client with coronary artery disease. d) The statin medication to the client diagnosed with atherosclerosis. 205. Which client should the cardiac nurse assess first after receiving the p.m. shift report? a) The client who is completing the second unit of PRBCs. b) The client who is crying after being informed of a terminal diagnosis. c) The client who refused to eat the dietary tray but got food from home. d) The client who became short of breath ambulating in the hallway. 206. The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? a) The client diagnosed with arterial occlusive disease who has intermittent claudication. b) The client on strict bed rest who is complaining of calf pain and has a reddened calf. c) The client who complains of low back pain when lying supine in the bed. d) The client who is upset because the food doesn’t taste good and is cold all the time. 207. The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone? a) The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm. b) The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36. c) The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL. d) The client who is 8 hours postoperative for exploratory laparotomy with a serum potassium of 4.5 mEq/L. 208. The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first? a) Ask the HCP to order a stat lung scan. b) Place oxygen on the client via nasal cannula. c) Prepare to administer intravenous heparin. d) Tell the client not to ambulate and remain in bed. 209. Which client should the charge nurse assign to the new graduate on the respiratory unit? a) The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10. b) The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. c) The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. d) The client diagnosed with pneumonia who has a pulse oximeter reading of 91% and a CRT >3 seconds. 210. The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arms. The client states she fell on an ashtray and doesn’t want to talk about it. Which nursing intervention is priority? a) Document the objective findings in the client’s chart. b) Tell the client she must talk about the situation with the nurse. c) Report the situation to the Adult Protective Services. d) Take photographs of the bruises and cigarette burns. 211. The nurse observes an LPN crushing nifedipine (Procardia XL) before administering the medication to a client with arterial hypertension who has difficulty swallowing pills. Which intervention should the nurse implement first? a) Tell the LPN to take the client’s blood pressure. b) Take no action since this is appropriate behaviour. c) Show the LPN where to find pudding for the client. d) Tell the LPN this medication cannot be crushed. 212. The nurse has just received the a.m. shift report. Which client would the nurse assess first? a) The client with a venous stasis ulcer who is refusing to eat the high protein meal. b) The client with varicose veins who is refusing to wear thromboembolic hose. c) The client with arterial occlusive disease who is refusing to elevate their legs. d) The client with deep vein thrombosis who is refusing to stay in the bed. 213. Which nursing intervention is priority for the ICU nurse to implement when caring for a client diagnosed with diabetic ketoacidosis (DKA)? a) Assess for a fruity breath odor. b) Maintain the regular insulin IV rate on an infusion pump. c) Check blood glucose levels ac and hs. d) Monitor the client’s pulse oximeter readings. 214. The nurse is preparing to administer medications. Which medication should the nurse administer first? a) Acetaminophen (Tylenol), an analgesic, due in 5 minutes. b) Digoxin (Lanoxin), a cardiac glycoside, due at 0900. c) Furosemide (Lasix), a loop diuretic, due at 0800. d) Propoxyphene (Darvon), an analgesic, due in 2 hours. 215. The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? a) The routine oral medications for the clients. b) The bed baths and oral care. c) Evaluating the client’s progress. d) Transporting a client to dialysis. 216. The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? a) Notify the healthcare provider (HCP) immediately. b) Assess the client’s incisional wound. c) Prepare to administer dopamine, a vasopressor. d) Increase the client’s intravenous (IV) rate. 217. The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is most important for the nurse to ask the client? a) “Have you ever had a chest x-ray before?” b) “Can you hold your breath for a minute?” c) “Do you smoke or have you ever smoked cigarettes?” d) “Is there any chance you may be pregnant?” 218. Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? a) Changing the client’s subclavian dressing. b) Reinserting the client’s Foley catheter. c) Demonstrating ambulation with a walker. d) Getting the client up in a chair three times a day. 219. In the intensive care unit (ICU), the critical care nurse assesses a client diagnosed with an asthma attack who has a respiration rate of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement first? a) Call a Rapid Response Team (RRT). b) Increase the oxygen to 10 LPM. c) Check the client’s ABG results. d) Administer the fast-acting inhaler. 220. The client diagnosed with diabetes mellitus type 2 has a hemoglobin A1C of 11 mg/dL. Which intervention should the nurse implement first? a) Check the client’s current blood glucose level. b) Assess the client for neuropathy and retinopathy. c) Teach the client about the effects of uncontrolled hyperglycemia. d) Monitor the client’s BUN and creatinine levels. 221. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? a) Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. b) Request the UAP change the linens for the 89-year-old client with fecal incontinence. c) Tell the UAP to assist the 54-year-old client with a bowel management program. d) Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis. 222. The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? a) The client who has received three units of packed red blood cells (RBCs). b) The client scheduled for an esophagogastroduodenoscopy in the morning. c) The client with short bowel syndrome who has diarrhea and a K+ level of 3.3 mEq/L. d) The client who has just returned from surgery for a sigmoid colostomy. 223. Which task should the rehabilitation nurse delegate to the UAP? a) Tell the UAP to show the client how to perform self-catheterization. b) Ask the UAP to place the newly confused client in the inclusion bed. c) Request the UAP give the client 30 mL of Maalox, an antacid. d) Encourage the UAP to attend the multidisciplinary team meeting. 224. The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement? a) Take no action because this is appropriate delegation. b) Tell the UAP to obtain a bedside commode for the client. c) Discuss the inappropriate delegation of the nursing task. d) Document the situation in an adverse occurrence report. 225. The nurse and the unlicensed assistive personnel (UAP) are caring for a client on a medical unit who has difficulty swallowing and is incontinent of urine and feces. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? a) Check the client’s PEG feeding tube for patency. b) Place DuoDERM wound care patches on the client’s coccyx. c) Apply non-medicated ointment to the client’s perineum. d) Suction the client during feeding to prevent aspiration. 226. The client has cellulitis on the right lower leg. Which intervention should the nurse implement? a) Place the client’s right arm in the dependent position. b) Apply warm moist heat to the affected area. c) Wash the affected area with antistaphylococcal soap. d) Wrap the right arm with ACE bandages. 227. Which task is most appropriate for the home healthcare nurse to delegate to the UAP? a) Instruct the UAP to give the herb ginkgo biloba to the client with Alzheimer’s. b) Ask the UAP to perform the tube feedings for a client with a gastrostomy tube. c) Request the UAP to perform the daily colostomy irrigation for the client. d) Tell the UAP to wash and dry the client’s hair. 228. The male Mexican American client, who is terminally ill, refuses hospice services because he says it is “giving up” and he is not going to die. Which is the most appropriate action by the nurse? a) Discuss the philosophy and services of palliative care with the client. b) Take no other action and support the client’s decision. c) Contact the client’s healthcare provider to discuss the prognosis. d) Talk to the client’s family members about his choice to refuse hospice. 229. The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse? a) The client has hypoactive bowel sounds. b) The client’s output is 480 mL for 12-hour shift. c) The client has T 98.6, AP 98, RR 22, B/P 102/78. d) The client has coffee ground emesis. 230. The nurse is caring for a client 1 day postoperative sigmoid resection. There is a large amount of bright red blood on the dressing. Which intervention should the nurse implement first? a) Assess the client’s apical pulse and blood pressure. b) Auscultate the client’s bowel sounds. c) Notify the healthcare provider immediately. d) Reinforce the dressing with a sterile gauze pad. 231. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? a) Assisting the patient with oral hygiene b) Observing the patient's response to feedings c) Facilitating expression of grief or anxiety d) Initiating daily weighings. 232. The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? a) Administering IV fluids as prescribed by the physician b) Providing straws and offering fluids between meals c) Developing a plan for added fluid intake over 24 hours d) Teaching family members to assist the client with fluid intake 233. These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? a) Obtaining stool specimens for fecal blood test (Hemoccult) slides. b) Having the patient sign a colonoscopy consent form. c) Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY). d) Checking for allergies to contrast dye or shellfish. 234. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? a) 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal). b) 43-year-old patient with multiple myeloma who requires discharge teaching. c) 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy. d) 65-year-old patient with pernicious anemia who has just been admitted to the unit. 235. What is the priority nursing diagnosis for a client experiencing a migraine headache? a) Acute Pain related to biologic and chemical factors. b) Anxiety related to change in or threat to health status. c) Hopelessness related to deteriorating physiologic condition. d) Risk for Injury related to side effects of medical therapy. 236. The unlicensed assistive personnel (UAP) tells the nurse a female client, who had a laparoscopic cholecystectomy, is complaining of abdominal pain. Which intervention should the nurse implement first? a) Check the medication administration record for the last pain medication the client received. b) Instruct the UAP to ask the client to rate her pain on a 1 to 10 pain scale. c) Assess the client to rule out any postoperative surgical complications. d) Tell the UAP to obtain the client’s vital signs and pulse oximeter reading. 237. The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first? a) Ask the client if he has any prostate problems. b) Determine if the client has any betadine allergies. c) Lubricate the end of the indwelling catheter. d) Ensure urine is obtained in the indwelling catheter. 238. The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first? a) The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale. b) The aminoglycoside antibiotic vancomycin intravenous piggyback (IVPB) to the client with an infected abdominal wound. c) The proton-pump inhibitor pantoprazole (Protonix) IVPB to the client who is at risk for developing a stress ulcer. d) The loop-diuretic furosemide (Lasix) intravenous push (IVP) to the client who has undergone surgical debridement of the right lower limb. 239. The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? a) The UAP empties the indwelling catheter bag for the client with TURP. b) The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall. c) The UAP provides apple juice to the client with a nephrectomy who has been advanced to a clear liquid diet. d) The UAP applies moisture barrier cream to the elderly client with urinary incontinence who has an excoriated perianal area. 240. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? a) The 24-year-old client who had a circumcision and is being prepared for discharge. b) The client scheduled for a cystectomy who is crying and upset about the surgery. c) The client diagnosed with kidney cancer who is receiving two units of blood. d) The client who has end-stage renal disease and had an arteriovenous fistula created. 241. Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse? a) The LPN changes out a “sharps” container that is over the fill line. b) The LPN asks another nurse to observe wastage of a narcotic. c) The LPN has the trough drawn after hanging the aminoglycoside. d) The LPN inserts an indwelling urinary catheter into the client. 242. Which nursing task is most appropriate for the nurse to delegate to the UAP on the rehabilitation unit? a) Flush the triple-lumen lines on a central venous catheter. b) Assist with bowel training by escorting the client to the bathroom. c) Demonstrate for the client how to ambulate with a walker. d) Apply corticosteroid cream to the client with allergic dermatitis. 243. The unlicensed assistive personnel (UAP) reports to the nurse the client’s urine output has bright red blood. Which intervention should the nurse implement first? a) Instruct the UAP to take a urine specimen to the laboratory. b) Document the findings in the client’s nursing notes. c) Ask the UAP to take the client’s vital signs. d) Assess the client’s urine specimen and complete a renal assessment. 244. The elderly female client diagnosed with osteoporosis is prescribed the bisphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication? a) Administer the medication first thing in the morning. b) Ask the client whether she has a history of peptic ulcer disease. c) Encourage the client to walk for at least 30 minutes. d) Have the client remain upright for 30 minutes after administering the medication. 245. The nurse is preparing to perform a dressing change on a female client with end-stage renal disease. The nurse notes the client’s husband is silently holding the client’s hand and praying. Which action should the nurse implement first? a) Continue to prepare for the dressing change in the room. b) Call the chaplain to help the client and spouse pray. c) Quietly leave the room and come back later for the dressing change. d) Ask the husband whether or not he would like the nurse to join in the prayer. 246. The nurse is attempting to start an intravenous (IV) line in an elderly client who is dehydrated. After two unsuccessful attempts, which intervention should the nurse implement? a) Ask a second nurse to attempt to start the IV. b) Keep trying to get a patent IV access. c) Ask the HCP to order oral fluid replacement. d) Place cold packs on the client’s arms for comfort. 247. The client diagnosed with chronic kidney disease (CKD), and who has a left forearm graft, is assigned to the nurse and unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the nurse? a) The UAP avoids using soap while bathing the client. b) The UAP takes the BP on the client’s left arm. c) The UAP tells the client she should not eat chips. d) The UAP measures a scant amount of urine in the BSC. 248. The nurse is observing the unlicensed assistive personnel (UAP) provide care to a client with an indwelling catheter. Which action by the UAP warrants immediate intervention by the nurse? a) The UAP wears gloves when providing catheter care to the client. b) The UAP positions the collection bag on the side of the client’s bed. c) The UAP cares for the client’s catheter after washing his or her hands. d) The UAP does not secure the tubing to the client’s leg with tape. 249. The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? a) A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. b) A steroid to the client experiencing an acute exacerbation of multiple sclerosis. c) An anticholinesterase medication to a client diagnosed with myasthenia gravis. d) An antacid to a client with pyrosis who has called several times over the intercom. 250. The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? a) Change an abdominal dressing on a client who is 2 days postoperative. b) Check the client’s IV insertion site on the right arm. c) Monitor vital signs on a client who has just returned from surgery. d) Escort a client who has been discharged to the client’s vehicle. 251. The nurse is caring for clients in a long-term care facility. Which client should the nurse assess first after receiving the morning report? a) The client diagnosed with Parkinson’s disease who began to hallucinate during the night. b) The client diagnosed with congestive heart failure who has 3+ pitting edema of both feet. c) The client diagnosed with Alzheimer’s disease who was found wandering in the hall at 0200. d) The client diagnosed with terminal cancer who has lost 8 pounds since the last weight taken 4 weeks ago. 252. The clinic nurse is providing discharge instructions to an elderly client diagnosed with cataracts. Which intervention is most important for the nurse to implement? a) Encourage the client to wear dark glasses outside. b) Teach the client to increase the light in the home. c) Discuss the need to have the cataracts removed. d) Tell the family not to rearrange furniture in the home. 253. A wife tells the clinic nurse her husband had been fine and is now confused, doesn’t know where he is, and is not acting like his usual self. Which intervention should the nurse implement first? a) Perform a neurological assessment. b) Notify the client’s healthcare provider. c) Ask the wife to explain more about the behavior. d) Determine when the client last had something to eat. 254. The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? a) Encourage the client to move the buttocks every 2 hours. b) Order a high-protein diet to prevent skin breakdown. c) Get a pressure-relieving cushion to place in the wheelchair. d) Refer the client to physical therapy for transfer teaching. 255. The nurse is the first person on the scene of a motor vehicle accident. T he driver is in the driver’s seat unconscious. Which action should the nurse implement first? a) Stabilize the driver’s cervical spine. b) Do not move the client from the accident. c) Control any external bleeding. d) Ensure the driver has a patent airway. 256. Which task is most appropriate for the clinic nurse to delegate to the unlicensed assistive personnel (UAP)? a) Request the UAP to ride in the ambulance with a client. b) Ask the UAP to escort the client in a wheelchair to the car. c) Instruct the UAP to show the client how to use crutches. d) Tell the UAP to call the pharmacy to refill a prescription. 257. Which action by the unlicensed assistive personnel (UAP) warrants immediate intervention by the nurse? a) The UAP tied the confused client to a chair with a sheet. b) The UAP escorted the client downstairs to smoke a cigarette. c) The UAP bought the client a carbonated beverage from the cafeteria. d) The UAP assisted the client to ambulate to the dayroom area. 258. The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? a) Schedule for CT scan with contrast in a.m. b) Administer acetaminophen 2 PO for headache. c) Take client’s vital signs per protocol. d) Provide the client with a low-fat, low-cholesterol diet. 259. The nurse is at a park and observes a client fall and a stick become impaled into the right eye. Which intervention should the nurse implement first? a) Tell someone to call 911 immediately. b) Stabilize the stick in the client’s eye. c) Apply direct pressure to the right eye. d) Use a non-toxic liquid and irrigate the eye. 260. The nurse and unlicensed assistive personnel (UAP) are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. Which action is priority when moving the client in the bed? a) Do not attempt to move the client because of the weight. b) Get another UAP to help move the client in the bed. c) Obtain a lifting device made for lifting heavy clients. d) Tell the family that the client must assist in moving in the bed. 261. For which client’s laboratory data should the charge nurse notify the HCP? a) The potassium level of 3.6 mEq/L in a client diagnosed with heart failure who is taking the loop diuretic furosemide (Lasix). b) The PTT level of 78 in the client diagnosed with pulmonary embolism who is receiving IV heparin. c) The blood urea nitrogen (BUN) of 84 mg/dL in a client diagnosed with end-stage renal disease (ESRD) and peripheral edema. d) The blood glucose level of 543 mg/dL in a client diagnosed with uncontrolled diabetes mellitus type 1. 262. The charge nurse on a busy 20-bed endocrinology unit must send one staff member to the nursery. Which staff member is most appropriate to send to the nursery? a) The nurse who has worked on the endocrinology unit for 4 years. b) The graduate nurse who has been on the endocrinology unit for 6 months. c) The licensed practical nurse (LPN) who has worked in a newborn nursery at another facility. d) The unlicensed assistive personnel (UAP) who has six small children of her own. 263. The nurse is working in an endocrinology unit. Which client warrants immediate intervention by the nurse? a) The client with acromegaly who has club-like fingertips and large feet. b) The client with syndrome of inappropriate antidiuretic hormone who has decreased urine output. c) The client with Cushing’s syndrome who has truncal obesity and thin, fragile skin. d) The client with pheochromocytoma who has a severe pounding headache and chest pain. 264. Which client should the charge nurse on a medical unit assign to a nurse who is 3 months pregnant? a) The client who is receiving chemotherapy who is immunosuppressed. b) The client with postoperative hyperparathyroidism who has shingles (herpes zoster). c) The client with hyperthyroidism who is receiving radioactive iodine I-131. d) The client diagnosed with AIDS who has a cytomegalovirus infection. 265. Which task should the ambulatory care nurse delegate to the unlicensed assistive personnel (UAP)? a) Ask the UAP to remove the trash from the room of the client who received radioactive iodine with hyperthyroidism. b) Instruct the UAP to escort the client outside who is asking to smoke a cigar. c) Request the UAP check the surgical dressing on the client with an ileal conduit. d) Tell the UAP to take the glucometer reading on the client about to go to surgery. 266. The home health (HH) nurse is caring for a 22-year-old female client who sustained an L-5 spinal cord injury 2 months ago. The client says, “I will never be happy again. I can’t walk, I can’t drive, and I had to quit college.” Which intervention should the nurse implement first? a) Allow the client to ventilate her feelings of powerlessness. b) Refer the client to the home healthcare agency social worker. c) Recommend contacting the American Spinal Cord Association. d) Ask the client whether she has any friends who come and visit. 267. An elderly client diagnosed with thyroid cancer frequently makes statements that are inappropriate for the situation, and is not oriented to place, time, or date. The HCP has ordered an MRI scan of the client’s brain. Which intervention should the nurse implement? a) Administer a mild sedative to prevent claustrophobia. b) Order a vest restraint for use by the client during the MRI. c) Make sure the client does not have a pacemaker. d) Ask a family member to stay with the client while the test is performed. 268. The terminally ill client diagnosed with ALS (Lou Gehrig’s disease) has a DNR order in place and is currently complaining of “pain all over.” The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? a) Administer the narcotic pain medication IVP. b) Turn and reposition the client for comfort. c) Refuse to administer pain medication. d) Notify the HCP of the client’s vital signs. 269. The night nurse enters the client’s room and finds the client crying. The client asks the nurse, “Am I dying? I think something is terribly wrong with me, but no one is telling me.” The nurse knows the client has pancreatic cancer and has less than 6 months to live. Which response is an example of the ethical principle of veracity? a) “You are concerned no one is telling you something is wrong.” b) “Your diagnosis is pancreatic cancer.” c) “If you feel something is wrong you should speak with your doctor in the morning.” d) “What makes you think there is something wrong and you are dying?” 270. The hospice nurse caring for a client diagnosed with diabetes mellitus type 2 observes the client eating a bowl of ice cream. Which intervention should the nurse implement first? a) Allow the client to enjoy the ice cream. b) Check the client’s blood glucose. c) Remind the client not to eat ice cream. d) Suggest the client eat low-fat sweets. 271. The nurse is preparing to administer morning medications to the following clients. Which medication should the nurse administer first? a) The NSAID to the client diagnosed with osteoarthritis. b) The intravenous antibiotic to the client with cellulitis. c) The antiviral agent to the client with herpes zoster (shingles). d) The antihistamine to the client with urticaria and pruritus. 272. The client tells the nurse, “I have a mole on my back which is darker and getting larger.” Which intervention should the nurse implement first? a) Tell the client to use corticosteroid cream on the area. b) Recommend the client use SPF 15 when in the sun. c) Instruct the client to notify his or her healthcare provider immediately. d) Encourage the client to wear dark, woven clothing when outside. 273. The nurse is preparing to change a dressing on an 82-year-old client with a Stage III pressure ulcer. Which intervention should the nurse implement first? a) Check to determine whether the client has received pain medication. b) Obtain the needed equipment to perform the procedure. c) Remove the client’s old dressing with nonsterile gloves. d) Explain the procedure to the client in understandable terms. 274. The unlicensed assistive personnel (UAP) tells the nurse the client with a right above-the-knee amputation has a large amount of bright red blood on the right leg residual limb. Which action should the nurse implement? a) Tell the UAP to take the client’s pulse and blood pressure. b) Assess the client’s residual limb dressing. c) Remove the dressing to assess the incision. d) Request the UAP to reinforce the dressing. 275. The charge nurse, a licensed practical nurse (LPN), and two unlicensed assistive personnel (UAPs) are caring for clients. Which action is most appropriate for the charge nurse to assign/delegate? a) Ask the UAP to apply warm compresses to the client with tinea corporis. b) Request the LPN to apply antifungal cream to the client with tinea pedis. c) Tell the UAP to remove the toenail of the client with onychomycosis. d) Instruct the LPN to administer accutane to the client who is pregnant. 276. The charge nurse on the busy 36-bed rehabilitation unit must send one staff member to the emergency department (ED). Which staff member is the most appropriate person to send? a) The LPN who has worked on the rehabilitation unit for 3 years. b) The RN who has been employed on the rehabilitation unit for 8 years. c) The UAP who is completing the 4-week orientation to the rehabilitation unit. d) The RN who transferred to the rehabilitation unit from the medical unit. 277. The elderly wife of a client with a total hip replacement who is being discharged home tells the nurse, “I am really worried about taking my husband home. I don’t know how I will be able to take care of him.” Which intervention is most appropriate for the nurse? a) Refer the client to the home health nurse. b) Discuss the possibility of placing her husband in a nursing home. c) Request the client’s healthcare provider to talk to the wife. d) Allow the client’s wife to ventilate her feelings about the situation. 278. The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? a) Assess the client for any adverse reactions. b) Complete the incident or adverse occurrence report. c) Administer the correct intravenous antibiotic medication. d) Notify the client’s healthcare provider. 279. The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? a) Instruct the UAP to obtain the client’s serum glucose level. b) Request the LPN to change the central line dressing. c) Ask the LPN to bathe the client and change the bed linens. d) Tell the UAP to obtain urine output for the 12-hour shift. 280. Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? a) Check the pulse oximeter reading for the client on a ventilator. b) Take the client’s sterile urine specimen to the laboratory. c) Obtain the vital signs for the client in an Addisonian crisis. d) Assist the HCP with performing a paracentesis at the bedside. 281. The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? a) Instruct the UAP to apply sequential compression devices to the client on strict bed rest. b) Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. c) Request the UAP to prepare the client for a wound debridement at the bedside. d) Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit. 282. The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the LPN? a) The 6-year-old client diagnosed with sickle cell crisis. b) The 8-year-old client diagnosed with biliary atresia. c) The 10-year-old client diagnosed with anaphylaxis. d) The 11-year-old client diagnosed with pneumonia. 283. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? a) The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. b) The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. c) The client with renal calculi who is complaining of severe flank pain and has hematuria. d) The client with Addison’s disease who has bronze skin pigmentation and hypoglycemia. 284. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? a) The client who had surgery for an inguinal hernia and who is being prepared for discharge. b) The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. c) The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. d) The client who has end-stage renal disease and who has had an arteriovenous fistula created. 285. The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? a) The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. b) The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. c) The client diagnosed with Addison’s disease who is lethargic and has BP of 80/45, P of 124, and RR rate of 28. d) The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau’s sign. 286. The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? a) The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. b) The client diagnosed with pneumonia who has an oral temperature of 100.2°F. c) The client diagnosed with cystitis who complains of burning on urination. d) The client diagnosed with pancreatitis who complains of pain that is an 8. 287. The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the UAP? (Select all that apply.) a) Explain the procedure for using the patient-controlled analgesia (PCA) pump. b) Check the client’s abdominal dressing for drainage. c) Take and record the client’s vital signs. d) Empty the client’s indwelling catheter bag at the end of the shift. e) Assist the client to ambulate in the hallway three to four times a day. 288. The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? a) Apply a sterile dressing to a Stage IV pressure wound. b) Check the blood glucose level of a resident who is weak and shaky. c) Document the amount of food the residents ate after a meal. d) Teach the residents how to play different types of bingo. 289. The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? a) Apply the wound debriding paste to the wound. b) Keep the resident’s heels off the surface of the bed. c) Turn the resident at least every 2 hours. d) Encourage the resident to drink a high-protein shake. 290. The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? a) Place a Posey vest restraint on the client. b) Move the client to a room near the station. c) Ask the HCP for an antipsychotic medication. d) Raise all four side rails on the client’s bed. 291. The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, “I am having problems getting in and out of my bathtub.” Which intervention should the clinic nurse implement first? a) Determine whether the client has grab bars in the bathroom. b) Encourage the client to take a shower instead of a bath. c) Initiate a referral to a physical therapist for the client. d) Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs). 292. The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first? a) The 4-year-old child who fell and is complaining of left leg pain. b) The 3-year-old child who is drooling and does not want to swallow. c) The 8-year-old child who has complained of a headache for 2 days. d) The 10-year-old child who is thirsty all the time and has lost weight. 293. The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? a) The client diagnosed with a myocardial infarction (MI) who has an elevatedtroponin level. b) The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. c) The client diagnosed with end-stage liver failure who has an elevated ammonia level. d) The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL. 294. The unlicensed assistive personnel (UAP) accidentally pulled the client’s chest tube out while assisting the client to the bedside commode. Which intervention should the nurse implement first? a) Securely tape petroleum gauze over the insertion site. b) Instruct the UAP how to move a client with a chest tube. c) Assess the client’s respirations and lung sounds. d) Obtain a chest tube and a chest tube insertion tray. 295. The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? a) Take the routine vital signs for all the clients on the pediatric unit. b) Transcribe the HCP’s orders into the computer. c) Administer PO medications to a client diagnosed with gastroenteritis. d) Assess the urinary output of a client diagnosed with nephrotic syndrome. 296. Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis? a) The client’s serum creatinine level is 2.4 mg/dL. b) The client’s abdomen is soft to touch and nontender. c) The dialysate being removed from the abdomen is cloudy. d) The dialysate instilled was 1,500 mL and removed was 2,100 mL. 297. The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess? a) Why the client did not have a viable baby with the first pregnancy. b) If the mother received a Rhogam injection after the last pregnancy. c) The period of time between the client’s pregnancies. d) When the mother terminated the previous pregnancy. 298. The nurse has received the shift report. Which client should the nurse assess first? a) The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom. b) The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. c) The client diagnosed with pancreatitis who wants the nasogastric tube removed. d) The client diagnosed with osteoarthritis who is complaining of stiff joints. 299. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP? a) Sit with the 6-year-old client while the parent goes outside to smoke. b) Stay with the 4-year-old client during scheduled play therapy sessions. c) Position the 2-year-old client for the postural drainage therapy. d) Weigh the diaper of the 6-month-old client who is on intake and output (I&O). 300. The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? a) The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough. b) The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds. c) The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer. d) The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis. 301. The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? a) Administer a pain medication 30 minutes before therapy. b) Give the client a washcloth to wash his or her face before walking. c) Check to make sure the client has been offered the use of the bathroom. d) Find a walker that is the correct height for the client to use. 302. The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse’s best initial response? a) “If you don’t stop shouting, I will have to call security.” b) “I hear that you are frustrated. Can we discuss the issues calmly?” c) “Sir, you are disrupting the unit. Calm down or leave the hospital.” d) “This type of behavior is uncalled for and will not resolve anything.” 303. A major disaster has been called, and the charge nurse on a medical unit must recommend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? a) The client diagnosed with chronic angina pectoris who has been on new medication for 2 days. b) The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days. c) The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection. d) The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH 7.34; PCO2 55; HCO3 28; PaO2 89. 304. The client in a motor vehicle accident (MVA) is in critical condition with a pelvic fracture, flail chest, bilateral arm fractures, and a left hip fracture. The client tells the nurse, “I just want to die. I can’t feed myself or clean myself.” Which statement is the nurse’s best response? a) “I know this must be hard for you but you can have a life.” b) “I can see you must feel helpless; I am here to listen.” c) “Have you thought about killing yourself?” d) “You are in shock but in time things will get better.” 305. The client tells the nurse, “I do not like my doctor and I want another doctor.” Which statement is the nurse’s best response? a) “You should tell your doctor you are not happy with his care.” b) “Can you tell me what you don’t like about your doctor’s care?” c) “I will notify my nursing supervisor and report your concern.” d) “I am sorry, but you really must keep this doctor until you are discharged.” 306. The charge nurse received laboratory data on the following clients. Which client warrants immediate intervention by the charge nurse? a) The client with COPD who has ABGs of pH, 7.35; PaO2 , 77; PaCO2 , 57; HCO3 , 24. b) The client diagnosed with bilateral TKR who has a WBC count of 10,400. c) The client on antibiotic therapy who has a serum potassium level of 3.3 mEq/L. d) The client receiving TPN who has a glucose level of 145 mg/dL. 307. Which priority intervention should the nurse implement to help prevent pressure ulcers in the client who is on strict bed rest? a) Provide adequate skin care for the client. b) Turn the client every 2 hours or more often. c) Ensure sufficient nutritional intake. d) Use pressure-relieving devices such as waterbeds. 308. The nurse is using an electric patient “Hoyer” lift to transfer the client from the bed to a stretcher. Which priority intervention should the nurse implement? a) Have two staff members assist when using the lift. b) Ensure the client is correctly placed in the lift prior to moving. c) Lift the client slowly off the bed when turning on the lift. d) Ensure the stretcher is in the correct position and locked. 309. The nurse is at the local mall and a young woman starts having shortness of breath, has hives on her face and arms, and is complaining of itching. Which intervention should the nurse implement first? a) Tell a by-stander to call 911 immediately. b) Ask the woman if she has an EpiPen. c) Check the client for a medical alert bracelet. d) Place a soft cushion under the client’s head. 310. The client diagnosed with breast cancer who is positive for the BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse’s best response? a) “If it were me in this situation, I would consider having a bilateral mastectomy.” b) “You should discuss your treatment options with your HCP.” c) “What treatment options has your healthcare provider (HCP) discussed with you?” d) “Have you talked with your significant other (SO) about the treatment options available to you?” 311. The nurse is completing a head-to-toe assessment on a client diagnosed with breast cancer and notes a systolic murmur that the nurse was not informed of during report. Which action should the nurse implement first? a) Notify the HCP about the new cardiac complication. b) Document the finding in the client’s chart and tell the charge nurse. c) Check the chart to determine whether this is the first time a murmur has been identified. d) Ask the client whether she has ever been told she has an abnormal heartbeat. 312. The client diagnosed with lung cancer has a hemoglobin and hematocrit of 13.4 mg/dL and 40.1, a WBC count of 7800, and a neutrophil count of 62%. Which action should the nurse implement? a) Place the client in reverse isolation. b) Notify the HCP. c) Make sure no flowers are taken into the room. d) Continue to monitor the client. 313. The charge nurse is making assignments for the day. Which client should be assigned to the new graduate nurse? a) The 42-year-old client who has just returned to the unit after a breast biopsy. b) The 84-year-old client who has a chest tube that is draining bright red blood. c) The 38-year-old client who is 1 day postoperative with a temperature of 101.2ºF. d) The 55-year-old client who is complaining of unrelenting abdominal pain. 314. Which task is most appropriate for the surgical nurse to assign to the LPN? a) Tell the LPN to administer the aminoglycoside antibiotic to the client. b) Request the LPN to empty the client’s indwelling urinary catheter. c) Instruct the LPN to assess the client who was just transferred from PACU. d) Ask the LPN to determine if the client understands the discharge teaching. 315. The intensive care nurse is caring for a client and notes blood oozing out from under the Tegaderm dressing over the peripheral intravenous site, bleeding gums, and blood in the indwelling urinary catheter bag. Which intervention should the nurse implement first? a) Check the client’s hemoglobin/hematocrit (H&H) level. b) Monitor the client’s pulse oximeter reading. c) Apply pressure to the intravenous site. d) Notify the client’s healthcare provider. 316. The confused client in the critical care unit is attempting to pull out the IV line and the indwelling urinary catheter. Which action should the nurse implement first? a) Ask a family member to stay with the client. b) Request the UAP to stay with the client. c) Place the client in a chest restraint. d) Notify the HCP to obtain a restraint order. 317. The older adult client receiving chemotherapy complains that food just does not taste like it used to. Which intervention should the medical unit nurse implement first? a) Ask the dietician to consult with the client on food preferences. b) Medicate the client before meals with an antiemetic medication. c) Ask the HCP to suggest an over-the-counter nutritional supplement. d) Check the client’s current weight with the client’s usual weight. 318. A client had an allergic reaction to penicillin, an antibiotic, and was admitted to the hospital 2 weeks ago. The client is being seen at the clinic for a follow-up visit. Which priority intervention should the nurse implement? a) Recommend the client wear a medical alert bracelet. b) Encourage the client to tell the pharmacy about the allergy. c) Tell the client not to be around any person taking penicillin. d) Allow the client to ventilate feelings about the hospitalization. 319. The home health hospice nurse is making rounds. Which client should the nurse assess first? a) The client with end-stage heart failure who has increasing difficulty breathing. b) The client whose family has planned to surprise her with an early birthday party. c) The client who is complaining of being tired and irritable all the time. d) The client with chronic lung disease who has not eaten for 3 days. 320. A client diagnosed with cancer and receiving chemotherapy is brought to the emergency department (ED) after vomiting bright red blood. Which intervention should the nurse implement first? a) Check to see which antineoplastic medications the client has received. b) Start an IV of normal saline with an 18-gauge intravenous catheter. c) Investigate to see whether the client has a do not resuscitate (DNR) order written. d) Call the oncologist to determine what lab work to order. 321. The nurse is called to the room of a male client diagnosed with lung cancer by the client’s wife because the client is not breathing. The client has discussed having a DNR order written but has not made a decision. Which interventions should the nurse implement first? a) Ask the spouse whether she wants the client to be resuscitated. b) Tell the spouse to leave the room and then perform a slow code. c) Assess the client’s breathing and call a code from the room. d) Notify the oncologist the client has arrested. 322. Which client should the nurse in the post-anesthesia care unit (PACU) assess first? a) The client who received general anesthesia who is complaining of a sore throat. b) The client who had right knee surgery and has a pulse oximeter reading of 90%. c) The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse. d) The client who had abdominal surgery and has green bile draining from the N/G tube. 323. The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first? a) Increase the client’s intravenous rate. b) Assess the client’s vital signs. c) Apply a tourniquet above the amputation. d) Notify the client’s healthcare provider. 324. The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first? a) Document the findings in the client’s chart. b) Elevate the client’s right hand. c) Assess the radial pulse with the Doppler. d) Notify the client’s healthcare provider. 325. The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? a) Tell the unlicensed assistive personnel (UAP) to ambulate the client with the walker. b) Request a referral to the physical therapy department. c) Obtain a walker that is appropriate for the client’s height. d) Notify the social worker of the HCP’s order for a walker. 326. The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement? a) Ask the UAP to take the client’s vital signs. b) Request the UAP to log roll the client to the right side. c) Complete the neurovascular assessment on the client’s legs. d) Contact the physical therapist to check the client. 327. The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? a) The client diagnosed with flail chest who has just come from the operating room with a right-sided chest tube. b) The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy. c) The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact. d) The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism. 328. The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments? a) The RN will perform the shift assessments. b) The LPN should administer all IVP medications. c) The UAP will complete all a.m. care. d) The RN will monitor laboratory values. 329. The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? a) Reinsert the nasogastric tube for the client who has pulled it out. b) Complete the preoperative checklist for the client scheduled for surgery. c) Instruct the client who is being discharged home about colostomy care. d) Change the client’s surgical dressing that has a 20 cm area of drainage. 330. The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first? a) The client who is 4 hours postoperative for abdominal surgery who is complaining of abdominal pain and has hypoactive bowel sounds. b) The client who is 1 day postoperative for total hip replacement (THR) who has voided 550 mL of clear amber urine in the last 8 hours. c) The client who is 8 hours postoperative for open cholecystectomy who has a T-tube draining green bile. d) The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot. 331. The home health aide calls the home health nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first? a) Notify the client’s healthcare provider. b) Visit the client to assess the reddened area. c) Document the finding in the client’s chart. d) Refer the client to the wound care nurse. 332. The newborn nursery nurse has received report. Which client should the nurse assess first? a) The 2-hour-old infant who has nasal flaring and is grunting. b) The 6-hour-old infant who has not passed meconium stool. c) The 12-hour-old infant who refuses to latch onto the breast. d) The 24-hour-old infant who has a positive startle reflex. 333. The nurse is caring for a female client 3 days post–knee replacement surgery when the client complains of vaginal itching. The medication administration report (MAR) indicates the client has been receiving the antacid calcium carbonate (Maalox), the antibiotic ceftriaxone (Rocephin), and the anticoagulant enoxaparin (Lovenox). Which priority intervention should the nurse implement? a) Request the dietary department to send yogurt on each tray. b) Explain to the client this is the result of the antibiotic therapy. c) Notify the HCP on rounds of the client’s vaginal itching. d) Ask the client whether she is having unprotected sexual activity. [Show More]

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