A charge nurse is planning care for several clients on the unit. Which activities can the
nurse safely delegate to an unlicensed assistive personnel (UAP)?
1. Administer a nebulizer treatment to a client diagnosed with pneumonia.
2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago.
3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client.
4. Assist a client with obtaining a clean catch urine sample.
5. Remove an indwelling urinary catheter from a client. - 3,4
What should the nurse teach a pregnant client who comes to the clinic reporting
hemorrhoids and constipation?
1. Increased rectal pressure from the gravid uterus may result in hemorrhoids.
2. Hormones decrease maternal GI motility, resulting in constipation.
3. The client needs more fiber in the diet.
4. A mild laxative is recommended to alleviate constipation.
5. The client needs to increase fluid intake.
Rationale - 1,2,3,5
What statements by a new nurse would indicate to the charge nurse an understanding
of how to maintain skin integrity for a client on bedrest?
1. "Clients on bedrest should be placed on therapeutic mattresses."
2. "I will assess for the skin every 4 hours."
3. "I will assess the skin using the Braden scale."
4. "A pillow will be placed between the knees when client is side lying."
5. "The incontinent client will be kept clean and dry." - 1,3,4,5
The primary healthcare provider suspects the client has tuberculosis (TB) and
prescribes a Mantoux test. What precautions should the nurse take when administering
the Mantoux test?
1. Don sterile gloves.
2. Place the client on reverse isolation.
3. Wear a particulate respirator
4. Obtain a consent form.
5. Initiate airborne precautions. - 3,5
,Which finding should a nurse expect when assessing a healthy 65 year old client?
The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse
prior to that procedure being performed. Which statement by the new nurse would
indicate to the charge nurse that additional education is needed?
1. "Prior to suctioning, I will hyper-oxygenate the client."
2. "I will instill normal saline bullets to liquefy secretions."
3. "I will allow at least 20 seconds between suctioning passes."
4. "Suctioning will be limited to a maximum of three catheter passes." - 2
The nurse observes a client at a follow-up appointment using correct cane walking
technique but losing balance each time the quad cane is lifted off of the floor. The client
reports a history of recent falls. What is the best action for the nurse to take?
1. Inform the primary healthcare provider of the observations made regarding quad
cane use, and imbalance assessment.
2. Inform client that there are only a few assistive devices available to help with
ambulation.
3. Instruct the client on proper quad cane use.
4. Notify the primary healthcare provider after consulting with the neighbor. - 1
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar
hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate
treatment plan for this client will include?
What is most important for the nurse to do prior to initiating peritoneal dialysis?
1. Aspirate for placement.
2. Have the client void.
3. Irrigate the catheter for patency.
4. Warm the dialysate fluid. - 4
The nurse in the outpatient clinic performs an assessment on a client who takes
propranolol for management of palpitations associated with mitral valve prolapse. Which
,statement by the client should be reported immediately to the primary healthcare
provider?
1. "My resting pulse was 60 this morning."
2. "I feel a little short of breath when walking."
3. "I have lost 5 pounds in the last 2 weeks."
4. "My blood pressure (BP) was lower this visit than last time." - 2
Blood and urine samples are sent to the laboratory for a client who has had a spinal
cord injury. After reviewing these results, the nurse would expect which finding?
The nurse is instructing a client on achieving relaxation using deep breathing exercises.
Which statement by the client indicates to the nurse that further teaching is necessary?
1. "I can perform deep breathing exercises anywhere and at any time that I feel tension
and anxiety."
2. "I should sit or lie in a comfortable position, making sure my back is straight."
3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion."
4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds
before exhaling." - 3
A client diagnosed with pancreatitis becomes increasingly restless, confused and has
pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation =
90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take.
Initiate oxygen.
Insert another IV line.
Obtain blood sugar level.
Insert NG tube.
Repeat vital sign checks - This is the correct order
A teenage client is placed on life-support as a result of a motor vehicle accident (MVA).
Following an electroencephalogram (EEG), the client has been declared brain dead.
Which action by the nurse would take priority?
1. Call the respiratory department to have the ventilator removed.
2. Notify the facility's pastoral personnel.
3. Contact the regional organ procurement team.
4. Ask the family to select a funeral home. - 3
, A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic
one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has
not been able to sleep since being put on methyphenidate." What is the best response
for the nurse to make?
1. "I will discuss this with the primary healthcare provider. A different medication may be
prescribed."
2. "The insomnia will get better over time. Just wait it out."
3. "To prevent insomnia, give your child the last daily dose at least 6 hours before
bedtime."
4. "Your child may have overdosed on the medication. Go to the emergency department
now." - 3
A client has been admitted to the medical unit and placed on airborne precautions for
suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and
symptoms?
1. Weight gain
2. Fatigue
3. Hemoptysis
4. Diaphoresis during sleep
5. Anorexia - 2,3,4,5
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube.
In what order should the nurse perform this procedure?
Place actions in the correct order.
Elevate head of bed to fowler's position.
Measure distal NG tube from nose tip to earlobe to xiphoid process.
Lubricate 2-3 inches of distal NG tube.
Insert NG tube into unobstructed naris.
Advance NG tube upward and backward until resistance is met.
Rotate catheter and advance into nasopharynx.
Have client swallow ice as NG tube advances into stomach.
Secure NG tube. - This is the correct order
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which
client should the charge nurse assign to the neonatal nurse?
1. Undergoing surgery for placement of a central venous catheter.
2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy.
3. Receiving IV heparin for left leg thrombosis.
4. Admitted with a cerebrovascular accident. - 1
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