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EST UPDATE EXAM QUESTIONS & ANSWERS WITH RA
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TIONALES |A+ GRADE n n
n Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
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- Answer-Yes.
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A nurse on a med-surg unit has received change-of-
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shift report & will care for 4 clients.Which of the following client's needs may the nurse ass
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ign to an assistive personnel (AP)?
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A. Feeding a client who was admitted 24 hrs. ago w/aspiration pneumoni
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B. Reinforcing teaching w/a client who is learning to walk using a quad cane
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C. Reapplying a condom catheter for a client who has urinary incontinence
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D. Applying a sterile dressing to a pressure ulcer n n n n n n n
- Answer-C. Reapplying a condom catheter for a client who has urinary incontinence
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Rationale: The application of a condom catheter is a noninvasive, routine procedure thatthe
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nurse may delegate to the AP
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A client returning from surgery requires assessment and establishment of a plan of care.RN
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s are responsible for this, especially if the client is potentially unstable.
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A nurse observes an AP reprimanding a client for not using the urinal properly. The APtells
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n him she will put a diaper on him if he does not use the urinal more carefully next time. Whi
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ch of the following torts is the AP committing?
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A. Assault n n
,B. Battery
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C. False imprisonment
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D. Invasion of privacy
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- Answer-A. Assault n
Rationale: By threatening the client, the AP is committing assault.
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An adult client who is competent tells the nurse that he is thinking about leaving the hospital
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against medical advice. The nurse believes that this is not in the client's best interest, so she a
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dministers a PRN sedative med that the client has not requested alongw/his usual meds. Whi
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ch of the following tort has the nurse committed?
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A. Assault
B. False imprisonment n n
C. Negligence
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D. Breach of confidentiality
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- Answer-B. False imprisonment n n
Rationale: The nurse gave the med as a chemical restraint to keep the client from leavingthe
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facility against medical advice. The client did not consent.
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An RN is making assignments for client care to a LPN at the beginning of the shift.Which o
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f the following assignments should the LPN question?
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A. Assisting a client who is 24hr postop to use an incentive spirometer
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B. Collecting a clean- n n
,catch urine specimen from a client who was admitted on theprevious shift
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C. Providing nasopharyngeal suctioning for a client who has pneumonia
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D. Replacing the cartridge and tubing on a PCA pump n n n n n n n n
- Answer-D. Replacing the cartridge and tubing on a PCA pump
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Rationale: The RN is responsible for the PCA pump n n n n n n n n
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's
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office that he will prepare his advance directives before he goes to the hospital.Which of th
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e following statements by the client indicates to the nurse that he understandsadvance direc
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tives?
A. "I'd rather have my brother make decisions for me, but I know it has to be my wife."B.
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"I know they won't go ahead w/the surgery unless I prepare these forms."
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C. "I plan to write that I don't want them to keep me on a breathing machine."
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D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." -
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Answer-C.
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Rationale: The client has the right to decide and specify which medical procedures hewant
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s when a life-threatening situation arrives
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A client is about to undergo an elective surgical procedure. Which of the following actions
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are appropriate for the nurse who is providing people care regarding informedconsent? Sel
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ect all. n
, A. Make sure the surgeon obtained the client's consent
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B. Witness the client's signature on the consent form C.
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Explain the risks and benefits of the procedure
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D. Describe the consequences of choosing not to have the surgeryE
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. Tell the client about alternatives to having the surgery – Answer-
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A, B n
Rationale: The rest of the choices are the surgeon's responsibility, not the nurse
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A nurse has noticed several occasions in the past week when another nurse on the unit seem
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ed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleepin a cha
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ir in the break room when she was not on break. Which of the following actions should the
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nurse take? n
A. Remind the nurse that safe client care is a priority on the unit
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B. Ask others on the team whether they have observed the same behaviorC
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. Report observations to the nurse manager on the unit
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D. Conclude that her coworker's fatigue is not her problem to solve
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- Answer-C.
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Rationale: Any nurse who notices behavior that could possibly jeopardize client care orindi
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cate a substance abuse problem has a duty to report the situation immediately to the nurse m
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anager
A nurse is preparing info for a change-of-
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