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- A nurse is making rounds after receiving report. The nurse observes the client is receiving the wrong intravenous fluid. What is the nurse’s next action?
- Write an incident report, and submit it to the manager.
- Replace the bag of fluid with the fluid that was ordered.
- Report the incident to the charge nurse and the physician.
- Replace the fluid, and discuss the error with other staff nurses.
- A pediatric client who is known to have cancer is being admitted for mild neutropenia and a severe oral monilial infection. The nurse should assign the child to which room?
- A semi-private room with a medical patient
- A semi-private room with a surgical patient
- A private room without further precautions
- A private room with protective isolation
- A client who is legally blind has been admitted to the nursing unit. Which of the following activities should the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply.
- Assist the client with meals.
- Complete the admission interview form.
- Assess the impact of the lost vision on the client’s daily life.
- Assist the client to ambulate in the hall.
- Ask the client what community services are being utilized.
- A new nurse graduate is orienting to the psychiatric unit. Which of the following clients would be the best assignment for the new nurse?
- Depressed client who has newly reported being much happier
- Client who is manic, and is walking briskly about the unit
- Client who has schizophrenia, and is hearing voices
- Client who is suicidal, and is writing a note
- For the third time within a month, a client with borderline personality disorder took a handful of pills, called 911, and was admitted to the emergency department. The nurse overhears an unlicensed staff member say, "Here she comes again. If she was serious about committing suicide, she’d have done it by now." The nurse determines there is a need to teach the staff member which of the following?
- Clients with personality disorders rarely kill themselves.
- Each suicidal attempt should be taken seriously.
- Exploration of suicidal ideas and intent should be avoided.
- The nurse should prepare the client for direct inpatient admission.
- A client on the first day after abdominal surgery ranks his pain as 9 on a scale of 0 to 10, 0 being no pain and 10 being the most pain possible. He is laughing and talking with visitors at this time. The client has defined a pain level of 5 as his comfort level goal. He has an order for analgesics every 1 to 2 hours. His last dose was the maximum ordered 2 hours ago. He had no untoward effects. The nurse should do which of the following?
- Record his pain level at 5
- Administer the maximum dose of the analgesic
- Administer half the maximum dose of the analgesic
- Take his vital signs in 30 minutes
- As the nursing unit representative member serving on the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in?
- Tracking the number of accidents or incidents on the unit
- Documenting nursing time and activities spent on direct client care
- Administering a client and family satisfaction survey
- Assessing clients and report acuity to shift managers daily
- A 48-year-old client has just been diagnosed with a cancerous tumor in the abdomen. Which of the following nursing diagnoses is a priority?
- Risk for Ineffective Coping
- Risk for Imbalanced Nutrition: Less than Body Requirements
- Disturbed Self Concept
- Which of the following tasks is appropriate for the registered nurse (RN) to delegate to the licensed practical nurse (LPN)?
- Teaching a postop client about his diet
- Assessing a client with low blood pressure
- Ambulating a newly postoperative client
- Care of the ventilated client in the intensive care unit
- At the start of the shift there were only three newborns in the nursery, so staffing consisted of one RN and one LPN. Within two hours, three more newborns were admitted to the nursery, one requiring Level II care, and the parents of two newborns needed discharge teaching so they could go home. The RN was needed full time in the Level II nursery as the newborn was stabilized. What staffing is needed to provide appropriate care in this situation?
- The LPN can complete the admission assessments and discharge teaching for the five Level 1 newborns.
- An UAP from the postpartum unit can be reassigned to the nursery to do the discharge teaching.
- The RN can complete the admission assessments while continuing to stabilize the Level II newborn.
- Another RN needs to be assigned to the nursery to implement the admission assessments and discharge teaching.