Beruflich Dokumente
Kultur Dokumente
1. The nurse on the cardiac unit has received the 1. Discuss personal information the client shared
shift report from the outgoing nurse. Which client with the nurse in confidence.
should the nurse assess first? 2. Provide the case manager with any information
1. The client who has just been brought to the unit that is required for continuity of care.
from the emergency department 3. Explain that client confidentiality prevents the
(ED) with no report of complaints. nurse from disclosing information.
2. The client who received pain medication 30 4. Ask the case manager to get the client’s
minutes ago for chest pain that was a permission before sharing information.
level 3 on a 1-to-10 pain scale.
3. The client who had a cardiac catheterization in 7. The nurse assesses erratic electrical activity on
the morning and has palpable pedal the telemetry reading while the client is talking to
pulses bilaterally. the nurse on the intercom system. Which task
4. The client who has been turning on the call light should the nurse instruct the UAP to implement?
frequently and stating her care has 1. Call a Code Blue immediately.
been neglected. 2. Check the client’s telemetry leads.
3. Find the nurse to check the client.
2. The nurse on the cardiac unit is preparing to 4. Remove the telemetry monitor.
administer medications after receiving the morning
change-of-shift report. Which medication should the 8. The charge nurse on the cardiac unit has to float
nurse administer first? a nurse to the emergency department for the shift.
1. The cardiac glycoside to the client who has an Which nurse should be floated to the emergency
apical pulse of 58. department?
2. The loop diuretic to a client with a serum K+ level 1. The nurse who has 4 years of experience on the
of 3.2 mEq/L. cardiac unit.
3. The antidysrhythmic to the client in ventricular 2. The nurse who just transferred from critical care
fibrillation. to the cardiac unit.
4. The calcium-channel blocker who has a blood 3. The nurse with 1 year of experience on the
pressure of 110/68. cardiac unit who has been on a week’s sick leave.
4. The nurse who has worked in the operating room
3. Which client should the telemetry nurse assess for 2 years and in the cardiac unit for 3 years.
first after receiving the a.m. shift report?
1. The client diagnosed with deep vein thrombosis 9. The cardiac nurse is preparing to administer one
who has an edematous right calf. unit of blood to a client. Which interventions should
2. The client diagnosed with mitral valve stenosis the nurse implement? Rank in order of priority.
who has heart palpitations. 1. Infuse the unit of blood at 20 gtts/min the first 15
3. The client diagnosed with arterial occlusive minutes.
disease who has intermittent 2. Check the unit of blood and the client’s blood
claudication. band with another nurse.
4. The client diagnosed with congestive heart failure 3. Initiate Y-tubing with normal saline via an 18-
who has pink frothy sputum. gauge angiocatheter.
4. Assess the client’s vital signs and lung sounds,
4. The charge nurse is making assignments for and assess for a rash.
clients on a cardiac unit. Which client should the 5. Obtain informed consent for the unit of blood
charge nurse assign to a new graduate nurse? from the client.
1. The 44-year-old client diagnosed with a
myocardial infarction. 10. The charge nurse in the cardiac critical care unit
2. The 65-year-old client admitted with unstable is making rounds. Which client
angina. should the nurse see first?
3. The 75-year-old client scheduled for a cardiac 1. The client with coronary artery disease who is
catheterization. complaining that the nurses are being rude and
4. The 50-year-old client complaining of chest pain. won’t answer the call lights.
2. The client diagnosed with an acute myocardial
5. The charge nurse is making assignments for a infarction who has an elevated
30-bed cardiac unit staffed with three registered creatinine phosphokinase-cardiac muscle (CPK-
nurses (RNs), three licensed practical nurses MB) level.
(LPNs), and three unlicensed assistive personnel 3. The client diagnosed with atrial fibrillation on an
(UAPs). Which assignment is most appropriate by oral anticoagulant who has an International
the charge nurse? Normalized Ratio (INR) of 2.8.
1. Assign an RN to perform all sterile procedures. 4. The client 2 days’ postoperative coronary artery
2. Assign an LPN to give all IV medications. bypass who is being transferred to the cardiac unit.
3. Assign an UAP to complete the a.m. care.
4. Assign an LPN to write the care plans. Respiratory Management
6. The nurse on a cardiac unit is discussing a client 1. The nurse on a medical unit has a client with
with the case manager. Which information should adventitious breath sounds, but the nurse
the nurse share with the case manager?
is unable to determine the exact nature of the 3. Place the client in the Trendelenburg position.
situation. Which multidisciplinary team 4. Check the client’s surgical dressing.
member should the nurse consult first?
1. The healthcare provider. 8. The client in the post-anesthesia care unit
2. The unit manager. (PACU) has noisy and irregular respirations
3. The respiratory therapist. (Rs) with a pulse oximeter reading of 89%. Which
4. The case manager. intervention should the PACU nurse implement
first?
2. The nurse is working with a licensed practical 1. Increase the client’s oxygen rate via nasal
nurse (LPN) and an unlicensed assistive cannula.
personnel (UAP) to care for a group of clients. 2. Notify the respiratory therapist to draw arterial
Which nursing task should not be blood gases.
delegated or assigned? 3. Tilt the head back and push forward on the angle
1. The routine oral medications for the clients. of the lower jaw.
2. The bed baths and oral care. 4. Obtain an intubation tray and prepare for
3. Evaluating the client’s progress. emergency intubation.
4. Transporting a client to dialysis. ANSWERS
9. The day surgery admission nurse is obtaining
3. Which client should the charge nurse assign to operative permits for clients having surgery. Which
the new graduate on the respiratory unit? client should the nurse question signing the consent
1. The client diagnosed with lung cancer who has form?
rust-colored sputum and chest pain of 10 on a scale 1. The 16-year-old married client who is diagnosed
of 1 to 10. with an ectopic pregnancy.
2. The client diagnosed with atelectasis who is 2. The 39-year-old client diagnosed with paranoid
having shortness of breath and difficulty breathing. schizophrenia.
3. The client diagnosed with tuberculosis who has a 3. The 50-year-old client who admits to being a
non-productive cough and orange colored urine. recovering alcoholic.
4. The client diagnosed with pneumonia who has a 4. The 84-year-old client diagnosed with chronic
pulse oximeter reading of 91% and has a CRT >3 obstructive pulmonary disease (COPD).
seconds.
10. The intensive care unit (ICU) nurse is caring for
4. Which tasks are appropriate to assign to the a client on a ventilator who is exhibiting respiratory
unlicensed assistive personnel (UAP)? distress. The ventilator alarms are going off. Which
Select all that apply. intervention should the nurse implement first?
1. Perform mouth care on the client with 1. Notify the respiratory therapist immediately.
pneumonia. 2. Ventilate with a manual resuscitation bag.
2. Apply oxygen via nasal cannula to the client. 3. Check the ventilator to resolve the problem.
3. Empty the trashcans in the clients’ rooms. 4. Auscultate the client’s lung sounds.
4. Take the empty blood bag back to the laboratory.
5. Show the client how to ambulate on the walker. Gastrointestinal Management
7. The client who is 1 day postoperative following 3. Which client warrants immediate intervention
chest surgery is having difficulty breathing, has from the nurse on the medical unit?
bilateral rales, and is confused and restless. Which 1. The client diagnosed with dyspepsia who has
intervention should the nurse implement first? eructation and bloating.
1. Assess the client’s pulse oximeter reading. 2. The client diagnosed with pancreatitis who has
2. Notify the Rapid Response Team. steatorrhea and pyrexia.
3. The client with diverticulitis who has left lower all that apply.
quadrant pain and fever.
4. The client with Crohn’s disease who has right
lower abdominal pain and diarrhea.
7. The charge nurse is making assignments in the 2. The nurse is administering medications for clients
day surgery center. Which client should be on a neurological unit. Which medication should the
assigned to the most experienced nurse? nurse administer first?
1. The 24-year-old client who had a circumcision 1. A pain medication to a client complaining of a
and is being prepared for discharge. headache rated an 8 on 1 to 10 pain scale.
2. The client scheduled for a cystectomy who is 2. A steroid to the client experiencing an acute
crying and upset about the surgery. exacerbation of multiple sclerosis.
3. The client diagnosed with kidney cancer who is 3. An anticholinesterase medication to a client
receiving two units of blood. diagnosed with myasthenia gravis.
4. The client who has end-stage renal disease and 4. An antacid to a client with pyrosis who has called
had an arteriovenous fistula created. several times over the intercom.
8. The nurse is completing the admission 3. The nurse has just received the shift report.
assessment on the client scheduled for Which client should the nurse assess first?
cystectomy with creation of an ileal conduit. The 1. The client with Guillain-Barré syndrome who has
client tells the nurse, “I am taking saw palmetto for ascending paralysis to the knees.
2. The client with a C-6 spinal cord injury who has 1. Change an abdominal dressing on a client who is
autonomic dysreflexia. 2 days postoperative.
3. The client with Parkinson’s disease who is 2. Check the client’s IV insertion site on the right
experiencing “pill rolling.” arm.
4. The client with Huntington’s disease who has 3. Monitor vital signs on a client who has just
writhing, twisting movements of the face. returned from surgery.
4. Escort a client who has been discharged to the
4. The nurse and unlicensed assistive personnel client’s vehicle.
(UAP) are caring for a client with
right-sided paralysis. Which action by the UAP 10. Which client should the charge nurse assess
requires the nurse to intervene? first after receiving the change-of-shift report?
1. The UAP places the gait belt around the client’s 1. The client with a C-6 SCI who is complaining of
waist prior to ambulating. dyspnea and has a respiratory rate of 12
2. The UAP places the client on the abdomen with breaths/minute.
the client’s head to the side. 2. The client with an L-4 SCI who is frightened
3. The UAP places her hand under the client’s right about being transferred to the rehabilitation unit.
axilla to help the client move up 3. The client with an L-2 SCI who is complaining of
in bed. a headache and feeling very hot all of a sudden.
4. The UAP praises the client for performing 4. The client with a C-4 SCI who is on a ventilator
activities of daily living independently. and has a pulse oximeter reading of 98%.
6. The charge nurse on the endocrine surgical unit 1. The client diagnosed with breast cancer who is
is making assignments. Which task should be positive for the BRCA gene is requesting advice
delegated/assigned to the team members? from the nurse about treatment options. Which
1. Request the licensed practical nurse (LPN) statement is the nurse’s best response?
assess the client who is hypoglycemic. 1. “If it were me in this situation, I would consider
2. Ask the unlicensed assistive personnel (UAP) to having a bilateral mastectomy.”
assist feeding the client with an adrenalectomy who 2. “What treatment options has your healthcare
has a paralytic ileus. provider (HCP) discussed with you?”
3. Instruct the UAP to insert a nasogastric (N/G) 3. “You should discuss your treatment options with
tube into the client who has had a thyroidectomy. your HCP.”
4. Tell the LPN to perform an in and out 4. “Have you talked with your significant other (SO)
catheterization for the client diagnosed about the treatment options available to you?”
with acromegaly.
2. The staff nurse answers the telephone on a
medical unit and the caller tells the nurse that he
has planted a bomb in the facility. Which actions 4. Address the UAP to discuss why the tasks are
should the nurse implement? not being done as requested.
Select all that apply.
1. Do not touch any suspicious object. 8. The client is diagnosed with laryngeal cancer and
2. Call 911, the emergency response system. is scheduled for a laryngectomy next
3. Try to get the caller to provide additional week. Which intervention would be priority for the
information. clinic nurse?
4. Immediately pull the red emergency wall lever. 1. Assess the client’s ability to swallow.
5. Write down exactly what the caller says. 2. Refer the client to a speech therapist.
3. Order the client’s preoperative lab work.
3. The new graduate working on a medical unit 4. Discuss the client’s operative permit.
night shift is concerned that the charge nurse is
drinking alcohol on duty. On more than one 9. The charge nurse is making assignments for the
occasion, the new graduate has smelled alcohol surgical unit. Which client should be
when the charge nurse returns from a break. Which assigned to the new graduate nurse?
action should the new graduate nurse implement 1. The 84-year-old client who has a chest tube that
first? is draining bright red blood.
1. Confront the charge nurse with the suspicions. 2. The 38-year-old client who is 1 day postoperative
2. Talk with the night supervisor about the with a temperature of 101.2ºF.
concerns. 3. The 42-year-old client who has just returned to
3. Ignore the situation unless the nurse cannot do the unit after a breast biopsy.
her job. 4. The 55-year-old client who is complaining of
4. Ask to speak to the nurse educator about the unrelenting abdominal pain.
problem.
10. Which task is most appropriate for the surgical
4. The nurse is completing a head-to-toe nurse to assign to the licensed practical
assessment on a client diagnosed with breast nurse (LPN)?
cancer and notes a systolic murmur that the nurse 1. Tell the LPN to administer the aminoglycoside
was not informed of during report. Which action antibiotic to the client.
should the nurse implement first? 2. Request the LPN to empty the client’s indwelling
1. Notify the HCP about the new cardiac urinary catheter.
complication. 3. Instruct the LPN to assess the client who was
2. Document the finding in the client’s chart and tell just transferred from PACU.
the charge nurse. 4. Ask the LPN to determine if the client
3. Check the chart to determine whether this is the understands the discharge teaching.
first time a murmur has been identified.
4. Ask the client whether she has ever been told Women’s Health Management
she has an abnormal heartbeat.
1. Which client should the postpartum nurse assess
first after receiving the a.m. shift report?
5. The client diagnosed with lung cancer has a 1. The client who is complaining of perineal pain
hemoglobin and hematocrit (H&H) of 13.4 mg/dL when urinating.
and 40.1, a WBC count of 7800, and a neutrophil 2. The client who saturated multiple peri-pads
count of 62%. Which action should the nurse during the night.
implement? 3. The client who is refusing to have the newborn in
1. Place the client in reverse isolation. the room.
2. Notify the HCP. 4. The client who is crying because the baby will not
3. Make sure no flowers are taken into the room. nurse.
4. Continue to monitor the client.
2. Which newborn infant would warrant immediate
6. The charge nurse observes two unlicensed intervention by the nursery nurse?
assistive personnel (UAPs) arguing in the 1. The 1-hour-old newborn who has abundant
hallway. Which action should the nurse implement lanugo.
first in this situation? 2. The 6-hour-old newborn whose respirations are
1. Tell the manager to check on the UAPs. 52.
2. Instruct the UAPs to stop arguing in the hallway. 3. The 12-hour-old newborn who is turning red and
3. Have the UAPs go to a private room to talk. crying.
4. Mediate the dispute between the UAPs. 4. The 24-hour-old newborn who has not passed
meconium.
7. The graduate nurse is working with an
unlicensed assistive personnel (UAP) who has 3. The client in labor is showing late decelerations
been an employee of the hospital for 12 years. on the fetal monitor. Which intervention should the
However, tasks delegated to the UAP by the nurse implement first?
graduate nurse are frequently not completed. Which 1. Notify the healthcare provider (HCP)
action should the graduate nurse take first? immediately.
1. Tell the charge nurse the UAP will not do tasks 2. Instruct the client to take slow, deep breaths.
as delegated by the nurse. 3. Place the client in the left lateral position.
2. Write up a counseling record with objective data 4. Prepare for an immediate delivery of the fetus.
and give it to the manager.
3. Complete the delegated tasks and do nothing 4. The nurse walks into the client’s room to check
about the insubordination. on the mother and her newborn. The client states
another nurse just took her baby back to the 1. The 3-hour-old newborn who weighs 6 pounds
nursery. Which intervention should the nurse and 2 ounces.
implement first? 2. The 4-hour-old newborn delivered at 42 weeks’
1. Initiate an emergency Code Pink, indicating an gestation.
infant abduction. 3. The 6-hour-old newborn who is 22 inches long.
2. Ask the mother to describe the nurse who took 4. The 8-hour-old newborn who was born at 40
the baby. weeks’ gestation.
3. Determine whether the infant was returned to the
nursery. Pediatric Health Management
4. Ask the mother whether the nurse asked for the
code word. 1. The nurse is working in the emergency
department (ED) of a children’s medical
5. The nurse in the labor and delivery department is center. Which client should the nurse assess first?
caring for a client whose abdomen 1. The 1-month-old infant who has developed colic
remains hard and rigid between contractions and and is crying.
the fetal heart rate is 100. Which 2. The 2-year-old toddler who was bitten by another
client problem is priority? child at the day-care center.
1. Alteration in comfort. 3. The 6-year-old school-age child who was hit by a
2. Ineffective breathing pattern. car while riding a bicycle.
3. Risk for fetal demise. 4. The 14-year-old adolescent whose mother
4. Fluid and electrolyte imbalance. suspects her child is sexually active.