1. Angelina, an R.N., reports to work looking unkempt. Maegan, another R.N.

, approaches when she notices her using uncoordinated movements. Angelinas breath reeks of peppermints and Maegan suspects Angelina may be intoxicated. What is the best initial nursing action for Maegan to take? a. Call the supervisor and report Angelina. b. Confront Angelina, saying that she feels she is intoxicated, and relieve her of her nursing duties immediately. c. Ignore the situation. d. Give Angelina a lecture about substance abuse and do nothing else.

a. Dopamine drip IV with vital signs monitored every 5 minutes b. a myocardial infarction that is free from pain and dysrhythmias c. a tracheotomy of 24 hours in some respiratory distress d. a pacemaker inserted this morning with intermittent capture

7. A client asks the nurse to call the police and states: I need to report that I am being abused by a nurse. The nurse should first: a. focus on reality orientation to place and person b. assist with the report of the clients complaint to the police c. obtain more details of the clients claim of abuse d. document the statement on the clients chart with a report to the manager

2. Carol has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? a. To observe the type and amount of nasogastric tube drainage b. Monitor the client for nausea or other complications c. Irrigate the nasogastric tube with the ordered irrigant d. Perform nostril and mouth care

8. John, a client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurses response should be to: a. ask to not be assigned to this client or to work on another unit b. tell the client that such behavior is inappropriate c. inform the client that hospital policy prohibits staff to date clients d. discuss the boundaries of the therapeutic relationship with the client

3. Britney is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states I dont think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects. The nurse should understand that: a. a referral is needed to the psychiatrist who is to provide the client with answers b. the client has a right to know about the prescribed medications c. such education is an independent decision of the individual nurse whether or not to teach clients about their medications d. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

9. A client continuously calls out to the nursing staff when anyone passes the clients door and asks them to do something in the room. The best response by the charge nurse would be to: a. keep the clients room door cracked to minimize the distractions b. assign 1 of the nursing staff to visit the client regularly c. reassure the client that 1 staff person will check frequently if the client needs anything d. arrange for each staff member to go into the clients room to check on needs every hour on the hour

4. James with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the clients mental status and adjustment. The appropriate response of the nurse should be which of these statements? a. "I am sorry. Referral information can only be provided by the clients providers" b. "I can never give any information out by telephone. How do I know who you are?" c. "Since this is a referral, I can give you this information" d. "I need to get the clients written consent before I release any information to you"

10. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? a. Assign an RN to provide total care of the client b. Assign a nursing assistant to help the client with self-care activities c. Delegate complete care to an unlicensed assistive personnel d. Supervise a nursing assistant for skin care

11. A 24-year-old woman had surgery today. Her father, a physician but not her surgeon, enters the nursing station and asks for her chart. The best action for the nurse to take is: a. to give him the chart as requested. b. not to allow him to read the chart. c. to ask the attending surgeon if it is permissible for him to read the chart. d. to ask the client if she wants him to read her chart.

5. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is: a. "I must document and report any important information." b. "I cant make such a promise." c. "That depends on what you tell me." d. "I must report everything to the treatment team."

12. When assessing a client, it is important for the nurse to be informed about cultural issues related to the clients background because: 6. Helen, a nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with: a. Normal patterns of behavior may be labeled as deviant, immoral, or insane b. The meaning of the clients behavior can be derived from conventional wisdom

c. Personal values will guide the interaction between persons from 2 cultures d. The nurse should rely on her knowledge of different developmental mental stages

17. Mrs. Jefferson is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by: a. asking the client if she is Mrs. Jefferson. b. reading the clients identification bracelet c. reading the clients medical record. d. asking the roommate to state the clients name.

13. Robin, an adult male is scheduled for exploratory surgery this morning. After he is premedicated for surgery the nurse reviews his chart and discovers that he has not signed a consent form. The nurses action is based on which of the following understandings? a. Since the client came to the hospital consent is implied even if the consent for the surgery has not been signed. b. All invasive procedures require a consent form. c. The nurse should have him sign a consent form immediately d. The nurse should have the next of kin sign the necessary consent form

18. After working with a very demanding client, a nursing assistant tells the nurse, "I have had it with that client. I just cant do anything that pleases him. Im not going in there again." The nurses BEST response is: a. "He has a lot of problems. You need to be patient with him." b. "I will talk with him and try to figure out what to do." c. "He is scared and taking it out on you. Lets try to figure out what to do." d. "Ignore him and get the rest of your work done. Someone else can take care of him tomorrow."

14. Zantac is ordered for an adult client. The nurse mistakenly administered Xanax. What is the most appropriate action for the nurse to take? a. Notify the physician and document in the nurses notes that the physician was notified of the error. b. Notify the supervisor, complete a medication error incident report, and document in the nurses notes that an incident report was completed c. Notify the house supervisor, assess client carefully, and document only if adverse or untoward effects occur. d. Notify the physician, complete an incident report, and document the notification of the physician and any assessments made.

19. A client frequently compliments and invites the nurse to go out. The nurse should: a. Minimize further contact with the client b. Tell the client that his/her behavior is inappropriate c. Tell the client that hospital policy prohibits dating clients d. Discuss the boundaries of the relationship with the client

15. A client with Guillain-Barr syndrome has been on a ventilator for three weeks, and can communicate only with eye blinks because of quadriplegia. The intensive care nursing staff sometimes have no time for this tedious communication process. The clients family comes infrequently since they run a family-owned restaurant that does not close until visiting hours are over. How should the nurse respond to the familys request for exemption from visiting hours? a. Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff. b. Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients. c. Suggest that the family visit in shifts during the normal visiting hours, since the client needs to sleep at night. d. Make an exception to visiting regulations because of the long-term nature of the clients recovery and the need for family support.

20. Which one of the following could be safely delegated by the nurse to the nursing assistant? a. Observe a clients self-administration of insulin b. Cleanse and dress a small decubitus ulcer c. Monitor a clients response to physical therapy d. Apply and care for a clients rectal pouch

16. An adult client has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm. Because of the clients unstable condition, he is in the intensive care unit where visitors are limited to the family. The client insists on having a visit from a medicine man whom the family visits regularly. How should the nurse interpret this request? a. The principle of justice prohibits giving one client a privilege that other clients are not permitted. b. Faith healers do not meet the standards for clergy exemption from visitation rules. c. Medicine men are not approved by the hospital as legitimate health care providers. d. Provision of holistic care requires that the clients belief system is honored.

1. Answer B. Calling the supervisor is a secondary measure after confronting the nurse and relieving the nurse of her duties. You cannot always assume the supervisor will be immediately available, and client safety should be addressed first. When another nurse is unable to perform her nursing duties due to substance abuse, she should not be allowed to continue them, as client safety is a primary concern. Ignoring the situation is against the professional code of conduct for nurses. Angelina needs to be relieved of her duties. She probably would not benefit from a lecture in her condition. 2. Answer D. Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation. 3. Answer B. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies. 4. Answer D. In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared. 5. Answer B. Secrets are inappropriate in therapeutic relationships and

are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality. 6. Answer B. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client. 7. Answer C. Obtain more details of the clients claim of abuse. The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint. 8. Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. 9. Answer B. Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed. 10. Answer D. Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed. 11. Answer B. The nurse must maintain the clients right of confidentiality. Since he is not the clients physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. Since he is not the clients physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. It is not the attending surgeon who can give permission for him to review the chart, it is the client. The client must give written permission for unauthorized persons to review her chart. This client had surgery today and is probably not alert enough to give legal permission, which must be written. 12. Answer A. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities 13. Answer B. It cannot be legally assumed that the client consents to a procedure for which he has not given consent. This is not legally defensible. All invasive procedures require informed consent. The surgery is prescheduled and described as exploratory and therefore is not an emergency. If the client is an adult and has not been declared incompetent the client must sign the form. This client should not have surgery performed without written consent. The nurse must notify the physicianimmediately. The client has been premedicated for surgery and is not alert. He cannot give legal consent when under the influence of mindaltering drugs. The client is an adult and there is no evidence that he has been declared incompetent to make his own decisions. The surgery is exploratory. There is no indication it is for an immediately life-threatening condition. It is not appropriate to ask the next of kin to sign his consent form. 14. Answer D. In addition to notifying the physician and documenting it, the nurse should complete an incident report. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurses notes. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurses notes. The physician

must be notified of the medication error. An incident report should be completed. However, no record of the incident report should appear in the nurses notes. The nurse should document that the physician was notified and any assessments completed. 15. Answer D. The need for family support is vital to prevent discouragement and depression. A volunteer will not take the place of family. The need for family support is vital to prevent discouragement and depression, even at the risk of offending the families of other patients. Loss of a breadwinner during the lengthy recovery process may add financial problems for the family. Guillain-Barr syndrome is characterized by the onset of ascending paralysis, which may include respiratory muscles. Persons with Guillain-Barr syndrome may remain ventilatordependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-Barr syndrome is good, but is very much dependent upon the level of supportive care during the acute stage. 16. Answer D. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. 17. Answer B. An alert, oriented client should be asked to state her full name so that there is no confusion in identity. The ID bracelet will confirm identity when the client is not alert or oriented to person. Reading the name on the clients ID bracelet is the most accurate way to confirm identity. Reading the clients medical record will not confirm identity. The roommate is not an accurate source for client identification. 18. Answer C. This response explains the clients behavior without belittling the nursing assistants feelings. The nursing assistant is encouraged to help solve the problem with the nurse. 19. Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. 20. Answer D. The RN may delegate the application and care of rectal pouches to a nursing assistant, who should be capable of performing this task .