Question 1

The nurse receives report on 4 clients.  Which client should the nurse see first?

Accepted Answer

A)  Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone
B)  Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently
C)  Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement
D)  Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing changeE) B) and C)
F) B) and D)

Question 2

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0.  However, the client denies a previous pregnancy.  Which action by the nurse is appropriate?

Accepted Answer

A)  Adjust documentation to indicate that the client is a G1P0
B)  Ask the client and partner about a previous miscarriage or abortion
C)  Confirm the obstetric history when the client is alone
D)  Explain the importance of accurate information to the client and partnerE) All of the above
F) B) and D)

Question 3

The nurse has received report on the following clients.  Which client should the nurse assess first?

Accepted Answer

A)  Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg
B)  Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea
C)  Client with anemia and hemoglobin level of 7 g/dL (70 g/L)  who has a pulse of 110/min after ambulation
D)  Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/minE) None of the above
F) A) and C)

Question 4

The nurse is triaging victims at the site of a mass casualty incident.  Which victim should be seen first?

Accepted Answer

A)  Client with a head injury and fixed, dilated pupils
B)  Client with an open right femur fracture and palpable pedal pulses
C)  Client with full-thickness burns covering 85% total body surface area
D)  Client with shallow lacerations over legs and armsE) B) and D)
F) A) and B)

Question 5

A major earthquake has occurred.  Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings.  Multiple victims arrive at the triage area.  Which client should the nurse care for first?

Accepted Answer

A)  Client with charred, leathery skin over entire back, chest, and legs
B)  Client with cool skin, shivering from sitting in water until rescued
C)  Client with diabetes who was unable to take prescribed insulin today
D)  Client with high-pitched, crowing inspiratory respirationsE) C) and D)
F) B) and D)

Question 6

An admitted emergency department (ED)  client is waiting for an intensive care unit (ICU)  bed to be available for transfer to the inpatient unit.  The ED is very crowded today.  The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours.  What action should the ED charge nurse take first?

Accepted Answer

A)  Call the telemetry unit manager
B)  Notify the nursing supervisor
C)  Send the client to ICU to "hold" the client in the hallway
D)  Wait until the resident has time to request the transferE) B) and C)
F) B) and D)

Question 7

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

Accepted Answer

A)  Assess for copious secretions to determine exposure
B)  Assist the victims farthest from the source first
C)  Assist the victims with the most severe symptoms first
D)  Monitor for diplopia to determine extent of exposureE) All of the above
F) None of the above

Question 8

The office nurse receives 4 telephone messages.  Which client should the nurse call back first?

Accepted Answer

A)  28-year-old female client who fell on ice yesterday and has low back pain and spasm
B)  42-year-old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights
C)  65-year-old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F (38.4 
C)  
D)  70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low backE) A) and B)
F) A) and C)

Question 9

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

Accepted Answer

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

Question 10

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

Accepted Answer

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

Question 11

The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action?  Select all that apply.

Accepted Answer

A)  Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement
B)  Advises a client's transport technician, "This client has metastatic breast cancer and must be moved very carefully due to fragile bones."
C)  Asks a client quietly, "When were you diagnosed with diabetes?" during admission assessment in a semiprivate room with the privacy curtain in place between beds
D)  Explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record
E)  Writes a client's last name on a whiteboard hanging in the nurses' station on which scheduled procedures are loggedF) A) and B)
G) A) and C)

Question 12

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse.  The adolescent asks to be tested for a sexually transmitted infection (STI) .  How should the clinic nurse respond?

Accepted Answer

A)  Determine if the client wore protection
B)  Inform that parental consent is required
C)  Inform that the request is honored if the client has symptoms
D)  Provide requested serviceE) B) and D)
F) C) and D)

Question 13

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

Accepted Answer

A)  Ambulate an oxygen-dependent client to the bathroom
B)  Assist client with dentures to perform oral suctioning after the client's meal
C)  Document pulse oximetry of a client with chronic obstructive pulmonary disease
D)  Instruct a client with pneumonia on use of the incentive spirometer
E)  Turn and reposition a client with pneumoniaF) None of the above
G) B) and D)

Question 14

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury.  Which room assignment is the most appropriate for this client?

Accepted Answer

A)  Room A:  Client with multiple myeloma who is being treated with corticosteroids
B)  Room B:  Client with diabetes mellitus and osteomyelitis receiving IV antibiotics
C)  Room C:  Client with a gastrointestinal bleed who has a nasogastric tube
D)  Room D:  Client with influenza with a high fever who is receiving oseltamivirE) B) and D)
F) B) and C)

Question 15

The nurse receives report on 4 clients.  Which client should the nurse assess first?

Accepted Answer

A)  Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea
B)  Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago
C)  Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9
D)  Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV siteE) A) and B)
F) A) and C)

Question 16

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

Accepted Answer

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

Question 17

The nurse in the emergency department receives 4 clients.  Which client should the nurse see first?

Accepted Answer

A)  Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
B)  Child with an abscess on the buttock that is red, swollen, and warm to the touch
C)  Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
D)  Child with low-grade fever, barking cough, and runny nose who has mild retractionsE) A) and D)
F) A) and B)

Question 18

Which client condition is concerning and requires further nursing assessment and intervention?  Select all that apply.

Accepted Answer

A)  Before liver biopsy, pulse is 80/min and blood pressure (BP)  is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg
B)  Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg
C)  Client with coronary artery disease on metoprolol; pulse is 62/min
D)  Elderly client with black stools; pulse is 112/min
E)  Neonate crying inconsolably at feeding time; pulse is 160/minF) A) and E)
G) C) and D)

Question 19

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

Accepted Answer

A)  A 2-month-old who rolled off the changing table and is now lethargic
B)  A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth
C)  A 3-year-old with forehead bruises that the mother says come from running into a table
D)  A 4-year-old who pulled boiling water off the stove and has splattered burns on the armsE) All of the above
F) None of the above

Question 20

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

Accepted Answer

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

Exam 5: Leadership & Management

The office nurse receives 4 telephone messages. Which client should the nurse call back first?

Correct Answer
verified

The nurse receives report on 4 clients. Which client should the nurse assess first?

Correct Answer
verified

The nurse has received report on the following clients. Which client should the nurse assess first?

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

Correct Answer
verified

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply.

Correct Answer
verified

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

Correct Answer
verified

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

Correct Answer
verified

The nurse receives report on 4 clients. Which client should the nurse see first?

Correct Answer
verified

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

Correct Answer
verified

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client?

Correct Answer
verified

The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? Select all that apply.

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

The nurse in the emergency department receives 4 clients. Which client should the nurse see first?

Correct Answer
verified

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

Correct Answer
verified

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first?

Correct Answer
verified

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate?

Correct Answer
verified

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI) . How should the clinic nurse respond?

Correct Answer
verified

Exam 5: Leadership & Management

The office nurse receives 4 telephone messages. Which client should the nurse call back first?

Correct AnswerverifiedShow Answer

The nurse receives report on 4 clients. Which client should the nurse assess first?

Correct AnswerverifiedShow Answer

The nurse has received report on the following clients. Which client should the nurse assess first?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply.

Correct AnswerverifiedShow Answer

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

Correct AnswerverifiedShow Answer

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

Correct AnswerverifiedShow Answer

The nurse receives report on 4 clients. Which client should the nurse see first?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client?

Correct AnswerverifiedShow Answer

The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? Select all that apply.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The nurse in the emergency department receives 4 clients. Which client should the nurse see first?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first?

Correct AnswerverifiedShow Answer

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate?

Correct AnswerverifiedShow Answer

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI) . How should the clinic nurse respond?

Correct AnswerverifiedShow Answer

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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