NURS 627 MANAGEMENT PRACTICE QUESTIONS AND ANSWERS

NURS 627 MANAGEMENT PRACTICE QUESTIONS AND ANSWERS 1. A 25 year old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client? A. Unlicensed assistive personnel (UAP) B. Senior nursing student C. PN D. RN The correct answer is D: The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to others listed. 2. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A. A client admitted with multiple trauma with a history of a newly implanted pacemaker B. A new admission with left-sided weakness from a stroke and mild confusion C. A 53 year old client diagnosed with cardiac arrest from a suspected myocardial infarction D. A 35 year old in balanced traction admitted 6 days ago after a motor vehicle accident The correct answer is D: A 35 year old client in balanced traction admitted 6 days ago after a motor vehicle accident. The client is the most stable with a predictable outcome. 3. A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? A. Teach the client how to cough up secretion. B. Change the tracheostomy trach ties. C. Monitor if client has shortness of breath D. Perform routine tracheostomy dressing care The correct answer is D: Perform routine tracheostomy dressing care. Unlicensed assistive personnel should be able to perform routine tracheostomy care. 4. An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? A. “How long have you been a UAP?” B. “What type of care did you give in pediatrics?” C. “Do you have your competency checklist that we can review?” D. “How comfortable are you to care for adult clients?” Review information: The correct answer is C: “Do you have your competency checklist that we can review?” The UAP must be competent to accept the delegated task. Further assessment of the qualification of the UAP is important in order to assign the right task. 5. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse to determine the client’s: A. Level of consciousness B. Pulse and blood pressure C. Respiratory rate and depth D. Ability to move extremities The correct answer is C – The first action of the nurse is to ensure that the client has adequate airway and respiratory status. In rapid sequence, the client’s circulatory status is evaluated (option B), followed by evaluation of the neurological status (options A and D). 6. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the forth cervical vertebra (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit? A. Listen to breath sounds B. Observe for dyskinesia’s C. Take the client’s temperature D. Assess extremity muscle strength The correct answer is A – Because compromise of respiration is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorder, so they are not as important in spinal cord related injured clients, unless head injury accompanies the spinal cord injury. 7. A 52 year old male client is seen in the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks. The client’s height is 5feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per minute, and respiration 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg/dL. Which of the following questions should the nurse ask the client first? A. Do you exercise regularly? B. Are you considering trying to lose weight? C. Is there a history of diabetes mellitus in your family? D. When was the last time you had your blood pressure checked? The correct answer is D – The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client’s nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority attention on the client’s major modifiable risk factors. 8. Which one of these tasks can be safely delegated to a practical nurse (PN)? A. Asses the function of a newly created ileostomy B. Care for a client with a recent complicated double barrel colostomy C. Provide stoma care for a client with a well-functioning ostomy D. Teach ostomy care to a client and their family member The correct answer is C: Provide stoma care for a client with a well-functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. The client has minimal risk of instability of the situation. 9. The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on the client’s left arm. Which of these statements is most immediately accurate? A. The RN has no accountability for this situation B. The RN did not delegate appropriately C. The UAP is covered by the RN’s license D. The UAP is responsible for following instructions The correct answer is D: The UAP is responsible for following instruction. The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing. 10. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, and LPN, and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign the UAP? A. Assist with plans for any clients discharged B. Provide basic hygiene care to all clients on the unit C. Asses a client after an acute myocardial infarction D. Gather the vital signs of all clients on the unit The correct answer is B.: Provide basic hygiene care to all clients on the unit. Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients. 11. Which client data should the nurse act upon when a home health aide calls the nurse from the client’s home to report these items? A. “The client has complaints of not sleeping well for the past week” B. “The family wants to discontinue the home meal service, meals on wheels” C. “The urine in the urinary catheter bag is a deeper amber, almost brown color” D. “The partner says the client has slower days every other day” The correct answer is C: “The urine in the urinary catheter bag is of a deeper amber, almost brown color. Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation. 12. The nurse has performed the initial assessment of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately? A. Prolonged inspiration with each breath B. Expiratory wheezes that are suddenly absent in one lobe C. Expectoration of large amounts of purulent mucous D. Appearance of the use of abdominal muscles for breathing The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe. Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an emergency – the small airways are now collapsed. 13. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operative the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A. Notify both the surgeon and provider B. Administer the prn dose of albuterol C. Apply oxygen at 2 liters per nasal cannula D. Repeat the peak flow reading in 30 minutes The correct answer is B: Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client’s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately. 14. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A. 16 year old who had an open reduction of a fractured wrist 10 hours ago B. 20 year old in skeletal traction for 2 weeks since a motor cycle accident C. 72 year old recovering from surgery after a hip replacement 2 hours ago D. 75 year old who is in skin traction prior to planned hip pinning surgery The correct answer is C: 72 year old recovering from surgery after a hip replacement 2 hours ago. Look for the client who has the most imminent risk and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16 year old should be seen next because it is still the first post-op day. The 75 year old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should be seen next. The client who can safely be seen last is the 20 year old who is 2 weeks post-injury. 15. An RN is about to make first rounds after receiving and intershift report at 3 p.m. In what order should the RN see the following clients? 1. A 54 year old client 4 hours post-cardiac catheterization who had mild discomfort at the access site. 2. A client newly diagnosed with diabetes mellitus who needs reinforcement of sick day management guidelines. 3. A client who arrived 30 minutes ago from the postanesthesia care unit 4. A client who is ready for discharge but will not has transportation to home available until 5 p.m. 5. A client with pneumonia who has received two doses of IV antibiotics and has an oxygen saturation of 93% Answer: 3,5,1,4,2 Priority setting can be implemented using a variety of models. The client who is postoperative should be seen first because the client is newly arrived on the unit and is at most risk of becoming unstable or experiencing a change in clinical condition. The client with pneumonia should be seen next because the infection involves the airway, although saturation levels are higher than the critical value of 90% or less. The client who is 4 hours post-cardiac catheterization should be seen next to evaluate the site and conduct general assessment on the affected extremity. The client who will be discharged should be seen next to determine that there are no last minute needs or issues. The client who needs teaching should be seen last because this is not a physiological need. 16. The nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? A. A client complaining of muscle aches, a headache, and malaise B. A client who twisted her ankle when she fell while rollerblading C. A client with minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce. The correct answer is D: In an emergency department triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes in the eyes are classified as emergent and are the number one priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number two priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent and are the number three priority. 17. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse asses first? A. A client scheduled for a chest X-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift The correct answer is D: Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in option A, B, and C have needs that would be identified as intermediate priorities. 18. The registered nurse must delegate care of an assigned client to an unlicensed assistive person (UAP) for the shift. Which of the following clients would be best to delegate to the UAP. A. A client who would benefit from talking about the recent death of her husband. B. A client with a Foley catheter and nasogastric feeding who is on bed rest. C. A client with an ostomy who has persistent problems with leakage. D. A client who was transferred from the critical care unit 3 days ago and is ambulatory. The correct answer is D: Factors to consider when delegating care include complexity of task, problem-solving innovation required, unpredictability, and level of client interaction. The client in option D is best because this client is likely to be stable with a low level of unpredictability. The client in option A requires a high level of client interaction. The client in option B represents a more complex client. The client in option C represents a client who would benefit from problem-solving innovation. 19. Which of the following tasks would not be appropriate for the registered nurse to delegate to licensed practical (LPNs) or unlicensed assistive personnel (UAPs). A. Instructing the LPN to reinforce teaching of the RN’s assigned clients prior to discharge. B. Assigning UAPs to complete vital signs and document and report information on any changes in client status to the RN C. Asking the UAP to asses and evaluate the client response to IV pain medication D. Instructing the LPN to remove a dressing from a postoperative client’s abdominal wound. The correct answer is C: The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning and evaluation is the registered nurse. LPN functions include reinforcing teaching and removal of dressing. Assistive personnel may perform simple nursing interventions, but the registered nurse remains responsible for analyzing the data and the client outcome. 20. The RN is planning the client assignment for the day. Which of the following is the most appropriate assignment for the nursing assistant A. A client requiring a colostomy irrigation. B. A client receiving continuous tube feedings. C. A client who requires urine specimen collections. D. A client with difficulty swallowing food and fluids. The correct answer is C: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collection. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. 21. A young adult is admitted to the hospital for gall bladder surgery. The client is also diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which of development post-operatively? A. Unusual muscle weakness B. Mental confusion C. Delayed would healing D. Ataxia upon ambulation The correct answer is C. 22. A client has returned to the nursing unit following a tracheostomy. The nurse would place the highest priority on assessing which of the following? A. Respiratory rate and sounds B. Amount of oxygen ordered to be delivered C. How long ago patient received pain medication D. Status of tracheostomy dressing The correct answer is A. 23. A nurse is caring for a 2 month old child with transposition of the great vessels. Which of these interventions has highest priority? A. Providing comfort for parents B. Maintaining proper caloric intake C. Reducing stressors for infant D. Documenting vital signs The correct answer is C. 24. The registered nurse has finished reviewing the 7:00 a.m. shift report on a telemetry unit. Which of the following clients would be the best for the RN to assign to the licensed practical nurse? A. A 7-day post op CABG client with an infection in the sternal surgical incision, requiring dressings and irrigation B. A client who has just arrived on the unit from the emergency room for observation to rule out a myocardial infarction C. A client who has had a successful valve replacement therapy and will be discharged this morning D. A client who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) at 10:00 a.m. The correct answer is A. 25. A new nurse is caring for a 78 year old client diagnosed with dementia, who experienced a stroke 3 weeks ago. A nurse manager recognizes the need for further education regarding appropriate delegation of the client care when the new nurse state: A. “I’ve watched the nursing aide and I believe the nurse aide can feed the client safely.” B. “I’ll have the nursing aide reinforce with the client that swearing at staff is unacceptable.” C. “The client’s skin needs checked; the nurse aide (NA) can do that when showering the client.” D. “The client needs new slippers; the NA can show the client’s family the old slippers when they visit today.” The correct answer is B: The scope of practice for ancillary staff does not include the management of client care. Assessing the client’s skin in not a responsibility that the RN can delegate. Feeling reinforcement and securing supplies and activities that may be assumed by ancillary staff as deemed appropriate by the RN. 26. A student nurse is caring for a client recovering from abdominal surgery with a nasogastric tub in place. Standards of care indicate that placement should be verified at least every 8 hours. Which most appropriate method should the experienced nurse delegate to the student nurse for verifying placement once every 8 hours? A. Insertion of air via tub while listening over the left upper quadrant B. Aspiration of the tube to verify the color of gastric contents C. Analysis is pH level of aspirated fluids D. Verification of placement by X-ray The correct answer is C: Analysis of the pH level is the most accurate to differentiate gastric (pH 1 to 5) from the intestinal (pH 6 or greater) and pulmonary secretions (pH 7 or greater). The pH level is most appropriate to distinguish between gastric and intestinal fluid. This skill is appropriate to delegate to student nurse caring for the client. Insertion of air is not accurate because of the displacement of sound from within the GI tract of the bronchial system. Inspection is an assessment and only done by an RN. X-ray verification is only for initial insertion, not every 8 hours. 27. A nurse is admitting a surgical client from the postanesthisia care unit after an anterior colporrhaphy procedure. Which nursing action included in the immediate plan of care should the nurse delegate to a licensed nurse (LPN)? A. Complete an initial postoperative assessment B. Instruct the client about how to use the patient-controlled analgesia (PCA) pump C. Answer questions from the client’s husband about the Foley urinary catheter D. Take vital signs every 15 minutes The correct answer is D: The LPN education includes vital sign monitoring and recognizing and reporting changes to the RN. Client admission assessment requires RN-level education and experience. Client and family teaching also should be completed by the RN. 28. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant? A. Assisting a post-cardiac catheterization client who needs to lie flat to eat lunch B. Obtaining frequent oral temperatures on a client C. Accompanying a man being discharged to his transportation to home D. Collecting a urine specimen from a client The correct answer is A: Work that is delegated to others must be done consistent with the individual’s level of expertise and licensure or lack of licensure. Based on the options provided, the least appropriate activity for a nursing assistant would be assisting a post-cardiac catheterization client who needs to lie flat to eat lunch. Because the client needs to eat lying flat, the client is at risk for aspiration. The remaining three options do not include situations to indicate that these activities carry any risk. 29. A nurse is planning the client assignment for the day for the nursing team, which includes a licensed practical nurse (LPN) and a nursing assistant. Of the following clients, which would the nurse most appropriately assign to the LPN? A. A client with stable congestive heart failure who has early-stage Alzheimer’s disease B. A client who was treated for dehydration and is weak and needs assistance in bathing C. A client with emphysema who is receiving oxygen at 2 L/minute by nasal cannula and becomes dyspneic on exertion D. A client who is scheduled for an electrocardiogram and a chest x-ray examination The correct answer is C: The nurse would most appropriately assign the client with emphysema to the LPN. The client has an airway problem and has the highest-priority needs among the clients presented in the options. The clients described in option A, B and D can appropriately be cared for by the nursing assistant. 30. A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? A. A client with bladder cancer who will be receiving chemotherapy B. A client on bed rest who requires range-of-motion (ROM) exercise every 4 hours C. A new diabetes mellitus client scheduled for discharge D. A client scheduled to receive a blood transfusion The correct answer is B: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case the most appropriate assignment for the nursing assistant would be to care for a client on bed rest who requires ROM exercises. The nursing assistant is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require the assessment skills that a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require a predischarge will require a predischarge review of diabetic management instructions and potentially coordination of necessary home care services. 31. During a morning report, the day nurse is given information on the assigned clients. Which of the following clients should the nurse assess first? A. The 80 year old client with metastatic cancer to the brain who is confused and on one- to-one observation with a sitter in the room. B. The 55 year old client with breast cancer who is scheduled for a computed tomographic (CT) scan of the brain at 9 AM to rule out metastasis. C. The 60 year old client with leukemia who is receiving the first round of chemotherapy, which was started at 6:30 AM and is scheduled to end at noon. D. The 70 year old client who was admitted at 5 AM with the medical diagnosis of pneumonia and a temperature of 102.6° F, this client received (acetaminophen) Tylenol at 6:00 AM and now has a temperature of 100.0° F. The correct answer is C: The nurse would plan to see first the client who is receiving chemotherapy for the first time. This is the highest priority because of the potential side effects of the medication and the fact that this is the first dose the client has received. The confused client with a sitter is safe. The client who is scheduled for a CT scan can wait because her scheduled test is not until 9 AM. The client with fever (option C) is stable for now. 32. A nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and submerged into a local river. The initial action of the nurse it to: A. Supply the triage rooms with bottles of sterile water and normal saline. B. Call the laundry department and ask the department to send as many warm blankets as possible to the emergency department. C. Call the nursing supervisor to activate the agency disaster plan. D. Call the intensive care unit to request that nurses be sent to the emergency department. The correct answer is C: In an external disaster many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options A, B, and D may be additional measures that the nurse would take, the initial action would be to activate the disaster plan. 33. A labor and delivery room nurse just received report on four clients. The nurse should assess which client first? A. A primigravida client in the active stage of labor B. A multigravida client who was admitted for induction of labor C. A client who is not contracting, but has suspected premature rupture of the membranes D. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor. The correct answer is D: Magnesium sulfate is a central nervous system depressant and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/min), severe hypotension, and absent deep tendon reflexes. This client should be seen before the clients in option A,B, and C because these clients’ conditions are stable. 34. A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the hospital emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries? A. Bright red bleeding from a neck wound B. Penetrating abdominal injury C. Fractured tibia D. Open massive head injury in deep coma The correct answer is A: The client with arterial bleeding from a neck wound is in “immediate” need of treatment to save the client’s life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as “delayed”, requiring intervention within 30 to 60 minutes. A green or “minimal” designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of “expectant” is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last. 35. A nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel? Select all that apply. A. A client needing a bed bath B. A client needing to ambulate C. A client needing packed red blood cells D. A client requiring assistance with feeding E. A client needing to have vital signs checked F. A client needing to use the bedside commode The correct answer is A, B D, E, and F: Unlicensed assistive personnel can perform tasks that are noninvasive. Therefore, options A, B, D, E and F tasks that the unlicensed assistive personnel can perform. The client in option C must be cared for by a registered nurse. 36. A 75 year old client with diabetes mellitus s admitted to the hospital for cataract surgery. Which task can be delegated to the nursing assistant? A. Assist the client in ambulating in the hallway. B. Listen to the client express frustration or loss. C. Instruct the client on how to apply the eye drops. D. Review hand washing and hygiene practices with the client. Correct answer is A: Assisting the client to ambulating down the hallway is within the scope of the nursing assistant’s responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to client’s emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to nursing assistants. 37. A nurse attends an educational conference on leadership styles. A colleague at the conference who is employed at a large trauma center states that the leadership style at the trauma center is task oriented and directive. The nurse recognizes that the leadership style used at the trauma center is: A. Autocratic B. Situational C. Democratic D. Laissez-faire The correct answer is A: The autocratic style of leadership is task oriented and directive. Situational leadership styles uses a style depending on the situation or events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and an opportunity to grow professionally. Laissez-faire allows staff to work without assistance, direction, or supervision. 38. A nurse has received her client assignment for the day. Which client should the nurse care for first? A. The client receiving chemotherapy, who is on day 3 of a 5-day regimen and has a question about nutrition B. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area C. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site. D. The client admitted with the medical diagnosis of neutropenia who is afebrile and complaining of pain with urination. The correct answer is D: The client admitted with neutropenia should be cared for first. The while blood cells serve as the primary defense against infections by destroying bacteria in blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the physician because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy. The client who has a mastectomy is expected to have sensations of tightness and pulling. 39. A nurse has received her client assignment for the day. Which client should the nurse care for first? A. A client with a postoperative pain reported 7 out of 10, with 10 being the worst B. Shortness of breath in a client with emphysema who just ambulated C. Client with serious drainage on a incisional spinal would postlaminectomy D. Client requiring a preoperative intravenous antibiotic The correct answer is A: In this situation the client with the pain reported at 7 out of 10 should be cared for first. The pain will intensify and be harder to manage if treatment is delayed. Caring for the client in pain may delay administration of preoperative antibiotic but does not jeopardize safe and effective care. Shortness of breath is expected in a client with emphysema after ambulation and therefore is not the priority. Serious drainage is expected from surgical incision and does not indicate an emergency. 40. A nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A. A middle aged man with one foot trapped under the wreckage B. A crying teenager who is holding pressure on an arm laceration C. A young women who appears dazed and confused and is shivering D. A screaming middle-aged women looking frantically for her husband The correct answer is C: The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a person with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival. 41. A nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. Number, in order of priority, the actions that the nurse will take to perform this procedure. (Number 1 is the first priority action, and number 6 is the last action.) 1. Apply gloves and attach the suction tubing to the suction catheter. 2. Place the client in semi-Fowler’s position. 3. Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. 4. Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. 5. Turn on the suction device and set the regulator at 80 m Hg. 6. Hyperoxygenate the client. The correct answer is 2,5,1,6,4,3: The nurse positions the client first and then prepares the necessary equipment before donning gloves. The nurse hyperoxygenates the client both before and after suctioning. Next the nurse inserts the catheter into the tracheostomy until resistance is met and then pulls it back 1 cm., applies intermittent suction and slowly withdrawals the catheter while rotating it back and forth. The catheter is rinsed, and the nurse performs nasopharyngeal and oropharyngeal suctioning to clear the upper airways; the catheter is contaminated after the nasopharyngeal and oropharyngeal areas are suctioned. 42. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? A. A client requiring a colostomy irrigation B. A client receiving continuous tube feeding C. A client who requires urine specimen collections D. A client with difficulty swallowing food and liquids The correct answer is C: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the nursing assistant would be the care for the client who requires urine specimen collection. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. 43. The RN employed is a long term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? A. The client who requires a bed bath B. An older client requiring frequent ambulation C. A client who requires a 24-hour urine collection D. A client with an abdominal would requiring wound irrigations and dressing changes every 3 hours The correct answer is C: When delegating nursing assignments, the nurse needs to consider the skills and education level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical nurse (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. 44. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A. Be with a client who self-administers insulin B. Cleanse and dress a small decubitus ulcer C. Monitor a client’s response to passive range of motion exercises D. Apply and care for a client’s rectal pouch The correct answer is D: The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task. 45. A nurse employed in an emergency department is assigned to triage clients to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients A. A client complaining of muscle aches, a headache, and malaise B. A client who twisted her ankle when she fell while rollerblading C. A client with a minor laceration on the index finger while cutting an eggplant D. A client with chest pain who stated that he just ate pizza that was made with a very spicy sauce The correct answer is D: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available to govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priorities. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority. 46. The RN has received the assignment of the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? A. A client who is ambulatory B. A client scheduled for physical therapy at 1 p.m. C. A client with a fever who is diaphoretic and restless D. A postoperative client who has just received pain medication The correct answer is C: The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client’s needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority. 47. The nurse assigned to care for four clients. In planning client rounds, which client should the nurse asses first? A. A client scheduled for a chest x-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift The correct answer is D: Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options A, B, and C have needs that would be identified as intermediate priorities. 48. A client with a diagnosis of cancer is receiving morphine sulfate 10 mg subcutaneously every 3-4 hours for pain. When preparing the plan of care for the client, the nurse includes which priority plan? A. Monitor stools B. Monitor urine output C. Encourage client to cough and deep breathe D. Encourage fluid intake The correct answer is C: Use the ABC’s when prioritizing. Recall the morphine sulfate suppresses the cough reflex and respiratory reflex. 49. A nurse is assessing a client’s condition after cardioversion. Which of the following observations would be of greatest priority? A. Status of airway B. Oxygen flow rate C. LOC D. Blood pressure The correct answer is A: Nursing responsibilities after cardioversion include maintenance of airway, oxygen administration, assessment of vital signs, and dysrhythmia detection. 50. A nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? A. Cough/deep breathing exercises B. Leg exercises C. Asses the client understanding of procedure D. Instructions regarding fluid restriction The correct answer is A: After a cholecystectomy, breathing tends to be shallow because deep breathing is painful as a result of the location of the incision. 51. A nurse is planning client assignments for the day and needs to assign four clients. There is an RN, LPN, and two nursing assistants. Which of the following would the nurse most appropriately assign to the RN. A. Client with leg amputation that requires a dressing change B. Client requiring a bed bath C. Client requiring frequent ambulation D. Client admitted to the hospital during the night after experiencing an acute asthma attack. The correct answer is D: Client with asthma attach will require more frequent respiratory assessments. The LPN is allowed to do the dressing changes and the nursing assistant can give bed baths and ambulate patients. 52. An RN is planning the client’s assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? A. Client having difficulty swallowing foods/fluids B. Client that requires stool specimen collections C. Client requiring colostomy irrigation D. Client receiving continuous tube feeding The correct answer is B: A nursing assistant is allowed to collect stool specimens. A client with difficulty swallowing is at risk for aspiration and needs assessment. Colostomy irrigations and continuous tube irrigations are not performed by unlicensed professionals. 53. A RN employed in a long term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has an LPN and three nursing assistants on the nursing team. Which of the following clients would the nurse most appropriately assign to the LPN? A. Client who requires a bed bath B. Older client who needs frequent ambulation C. Client that required 24 hour urine collection D. Client with an abdominal would requiring would irrigations and dressing changes every 3 hours. The correct answer is D: Collecting a 24 hour urine specimen, ambulating and giving bed baths can be provided most appropriately by the nursing assistants. The LPN is skilled in wound irrigations and dressing changes. 54. Which of the following patients need immediate medical evaluation and should be classified as emergency? A. A 90 year old man who complains of increased calf pain but denies shortness of breath or trauma B. A 78 year old women with a history of deep vein thrombosis and complaints of fever and productive cough C. A 60 year old man with a 40 pack a year history of smoking, complaints of shearing back pain and pallor D. A 69 year old women with a history of diabetes mellitus and peripheral vascular disease who says her feet are numb The correct answer is C: The 60 year old man complaining of shearing back pain presents with assessment findings consistent with a dissecting or ruptured aortic aneurysm and shock. The mortality rate for dissecting and ruptured aneurysms is very high; therefore this patient requires immediate medical attention to save his life. The patient with calf pain is stable for now and exhibits no need for emergent care. The calf pain can be an arterial, venous, oncologic, muscular, or benign health alteration. The patient with a history of deep vein thrombosis presents with findings consistent with infection; however, she does not have emergent medical needs. The physical complaints from the patient with diabetes mellitus are most likely to be consistent with chronic complications of diabetes mellitus and therefore not emergent. 55. A patient who sustained a crush injury to the right lower leg in a farm tractor accident complains of numbness and tingling of the affected extremity. If the skin of the right leg appears pale and pedal pulse is weak, the nurse should first A. Loosen the dressing B. Notify the physician C. Increase the IV flow rate D. Document the finding as the only action The correct answer is B: The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as parethesia precede changes in vascular or motor signs. This is an emergency, and response time is important because of the rapid deterioration of the affected limb. The physician should be notified immediately. 56. When planning care for a patient with a C-5 spinal cord injury, which nursing diagnosis is the highest priority? A. Ineffective airway clearance due to high cervical spinal cord injury B. Risk of impairment of tissue integrity due to paralysis C. Altered patterns of urinary elimination due to quadriplegia D. Altered family and individual coping due to the extent of trauma The correct answer is A: Maintaining a patient airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnosis for a patent with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs. 57. A 67 year old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges, with the affected foot elevated on 2 pillows. The nurse would place highest priority on which of the following interventions? A. Ambulate the patient to the bathroom every 2 hours B. Ask the patient about preferred activities to relieve boredom C. Perform frequent position changes and range of motion exercises D. Allow the patient to dangle legs at the bedside every 2 to 4 hours The correct answer is C: The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should change the patient’s position frequently to promote lung expansion and perform range of motion exercises to prevent contractures. 58. A nurse has just given a patient a narcotic for pain relief and must now leave the unit. To whom should the nurse delegate the task of evaluating the patient’s response to the pain medication? A. Unit clerk B. Student nurse C. An RN D. Patient care aide The correct answer is C: Assessment and management of pain belongs only to the RN’s scope of practice. 59. Which of the following is an appropriate task for a nurse to delegate to a nursing assistant? A. Checking a physician’s new orders B. Changing a patient’s wound dressing C. Toileting a patient on bladder-training regimen D. Taking a blood pressure of a patient who has fallen The correct answer is C: Transcribing a physician orders, changing a patient’s wound dressing, and assessing a patient require interventions by licensed personnel. Toileting a patient on a routine basis is appropriate to delegate to a nursing student. 60. Which task could a staff nurse delegate to a certified nursing assistant? A. Making rounds with a physician B. Evaluating a patient’s response to pain C. Assessing a patient’s central venous line site D. Feeding a stroke patient who has minimal dysphagia The correct answer is D: The majority of state boards have addressed the issue of delegation and have developed rules that may offer specific guidelines regarding who can do what. The scope of practice for each level of care provider usually includes a description of the tasks that may be performed at that level. 61. When unit staffing includes unlicensed assistive personnel (UAP), which of the following is characteristic? A. UAP do not have clinical duties on a patient care unit. B. Delegating tasks to UAP is not in the scope of RN practice. C. Licensed personnel are accountable for the tasks delegated to the UAP. D. UAP have formal training and are able to function independently. The correct answer is C: Nurses remain accountable for patient outcomes whether or not the specific tasks are performed by nurses or nurse extenders. Accountability implies being responsible and answerable for actions or inactions of self or others in the context of delegation. UAP do not function independently but can have clinical duties on a patient care unit. Delegation of tasks is within the scope of RN practice. 62. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel UAP)? A. Asses and document skin turgor and color changes B. Test stool for occult blood and urine for glucose and report results C. Suggest foods high in iron and those easily consumed D. Report mental status change and the degree of mental clarity The correct answer is B: Test stool for occult blood and urine for glucose and report results. The UAP can do standard, unchanging procedures that require no decision making. 63. A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A. Ask the client the degree of relief and document the client’s response. B. Decrease the set rate on the pump by 2 ml/minute C. Check the IV site for drainage and loose tape D. Assist the client with ambulation and a gown change with supervision The correct answer is D: Assist the client with ambulation and a gown change with supervision. When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine task should be delegated since they require independent judgment. 64. A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor. A. Provide decubitus ulcer care and apply a dry dressing B. Bath and feed a client on bed rest C. Oral suctioning of a unresponsive elderly client D. Teaching a family intermittent (bolus) feeding via G-tube before discharge The correct answer is D: Teaching a family intermittent (bolus) feeding via G-tube before discharge. Initial teaching cannot be delegated to a UAP or a PN and must be done by RNs. 65. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assistant is of highest priority? A. Monitoring of heel breakdown B. Monitoring of bladder distention C. Monitoring of extremity shortening D. Monitoring of loss of balance ability of toenail beds The correct answer is D: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of balance of toenail beds, and pain that will not be relieved by opioids. Although bladder distention, extremely lengthening or shortening, or heel breakdown can occur, these complications are not potentially life threatening complications. 66. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing intervention after central line insertion? A. Prepare the client for a chest radiograph B. Asses the client’s temperature to monitor for infection C. Label the dressing with the date and time of catheter insertion D. Monitor the blood pressure to assess for fluid volume overload The correct answer is A: A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if the complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Labeling the dressing site is important but not the priority. Although BP assessment is always important in assessing a client’s status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. 67. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which assessment finding? A. Temperature of 99.4F, flat affect B. Fist clenched and pounding table C. Tearful, withdrawn, and isolated D. Blood pressure 160/100 mm Hg, pulse 120 bpm, respirations 18 breaths per minute The correct answer is B: Anxiety can lead to behavior that is harmful to the client and others. If safety is threatened, this is the priority. Tearfulness, withdrawal, isolation, and elevated vital signs are abnormal findings. However, these findings are not life threatening, although they should be monitored. After the client’s mental status is addressed and the client’s safety is ensured, the nurse should attend to the elevated vital signs. 68. A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? A. Notifying the American Cancer Society if the client’s diagnosis. B. Referring the client to a home health nurse for follow-up visits to provide colostomy care. C. Requesting Meal On Wheels to provide adequate nutritional intake. D. Asking an occupational therapist to evaluate the client at home. The correct answer is B: Many clients are discharged from acute care settings so quickly that they don’t receive complete instructions. Therefore, the first priority is to arrange for colostomy care. 69. A nurse works on a general medical-surgical unit where nurses work on 12 client-pods. Each pod is staffed by two RNs. When one of the nurses leaves the unit for any reason the other nurse cares for all 12 clients. If she needs help, she can call the agency’s in-house resource nurse. One evening, the remaining nurse, who was making rounds of the other nurse’s clients, found medication left at bedsides and a client with a blood-draw tourniquet on his arm. In addressing the problems, the nurse should; A. Ask for a meeting with the coworker and manager B. Speak to the coworker when she/he returns to the unit C. Correct the problem and submit a written report D. Inform the nurse-supervisor right away The correct answer is B: When a nurse discover substandard practice by another nurse, it’s always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns but a written report may not be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved. 70. A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit’s decision-making process and helps them improve their clinical skills. The nurse is functioning effectively in which role? A. Leader B. Authority C. Manager D. Autocrat The correct answer is A: A leader doesn’t have formal power and authority but influence the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager’s formal power and authority within the organization are detailed in her/his job description. An autocrat isn’t interested in guiding or encouraging staff or in being an effective role model. A manager derives her authority by virtue of the position with the organization. 71. The managers of the physical and occupational therapy neurological departments tell a nurse- manager of an adult rehabilitation unit that they’re concerned that the clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don’t allow sufficient time for performing nursing interventions. Which action by the nurse-manger is the best solution to this problem? A. Tell the nursing staff that the nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists. B. Meet with the physical and occupational therapy managers to identify scheduling solutions. C. Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff. D. Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself (nurse-manager) as a resource. The correct answer is D: In this situation, functioning as a democratic leader is best. The nursing and therapy staff who deal the day to day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The nurse manager, however, should be available to help. Meeting with only the managers of physical and occupational therapy reflects an autocratic manager. Without staff input, the nurse-manager won’t have the information needed to identify the best solution. By simply telling the nursing staff to follow the therapists’ schedules, the nurse-manager has abdicated responsibility for problem solving, yet the problem still exists. Determining problem solving options without staff input is indicative of a participative manager. A participative manager asks staff members for options, but staff members don’t have input into the actual problem solving. The lack of input may cause resentment and frustration. 72. Four clients injured in an automobile accident enter ED at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with: A. 2nd trimester pregnancy in pre-term labor B. Maxillofacial injury and gurgling respirations C. Severe head injury and no BP D. Lumbar spinal cord injury and lower extremity paralysis The correct answer is B: ABC’s!!! 73. Which of the following is the top priority during a client’s first outbreak of genital herpes? A. Analgesics to decrease pain B. Antivirals to cure the disease C. Anxiolytics to alleviate anxiety D. Antibiotics for a secondary infection The correct answer is A: Herpetic lesions are very painful, so the first priority is to provide comfort measures for the client. Antivirals are used to control the extent of the outbreak but they are not a cure. Anxiolytics may be appropriate but are not a priority. There is no evidence of a secondary infection in this client. 74. When developing a plan of care for a client with hypocalcemia, the nurse chooses which of the following as a high-priority nursing diagnosis? A. Potential complication: electrolyte excess B. Risk of injury related to sensorium changes C. Risk of injury related to tetany and seizures D. Deficient fluid volume The correct answer is C: Tetany and seizures are clinical manifestations of hypocalcemia. The nurse must be aware of all potential risks to the client based on physiological factors of the presenting illness and must plan for the client’s safety. The other nursing diagnoses are for hypercalcemia. 75. The nurse caring for a client with a calcium imbalance places highest priority on nursing interventions that help to manage: A. Renal signs and symptoms B. Cardiac changes C. Hematologic disorders D. Neuromuscular clinical manifestations The correct answer is D: Although all the systems are impacted by calcium imbalance, the major clinical manifestations of calcium imbalance are due to either increased or decreased neuromuscular irritability. 76. A client with peripheral vascular disease returns to the surgical care unit after having femoral- popliteal bypass grafting. Indicate which order the nurse should conduct assessment of this client. A. Postoperative pain B. Peripheral pulses C. Urine output D. Incision site The correct answer is B, D, C, A: Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make that the bypass graft is functioning this step should be done first. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output. Lastly, the nurse should determine the client’s level of pain. 77. An adolescent with type 1 diabetes mellitus is hospitalized for appendicitis. He is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client’s breath. The client uses Lispro insulin. His last meal was lunch, 2 hours ago. Place the following nursing actions in the order in which the nurse should perform them. A. Obtain a finger stick test for blood glucose. B. Start an IV infusion with normal saline solution. C. Administer Lispro. D. Notify the physician. The correct answer is B, A, D, C: The client is experiencing ketoacidosis. The first action is to initiate IV fluids to prevent further dehydration. Next, the nurse should obtain serum glucose values to report to the physicians, who will then order the appropriate dose of insulin. 78. A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client. A. Control hemorrhaging B. Replace fluids. C. Relieve the client’s anxiety. D. Maintain a patient’s airway. The correct answer is D, A, B, C: The goal that has the highest priority when a client has a massive bleed from esophageal varices is to maintain a patient airway. The nurse should position the client to prevent aspiration and asses respirations and oxygen saturation. The nurse should then assist the health care provider in controlling the hemorrhage by using balloon tamponade. Occtreotide (Sandostain) may be administered to reduce portal pressure. The third priority is to restore circulating blood volume with blood and IV fluids. Esophageal bleeding is an anxiety-provoking event for the client and, although life-saving measures are the priority, the nurse and health care team should explain procedures to the client and provide reassurance as needed. 79. The RN must delegate care of an assigned client to an unlicensed assistive person (UAP) for the shift. Which of the following clients would be best to delegate to the UAP? A. A client who would benefit from talking about the recent death of her husband. B. A client with a foley catheter and nasogastric feedings who is on bed rest. C. A client with an ostomy who has persistent problems with leakage. D. A client who was transferred from the critical care unit 3 days ago and is ambulatory. The correct answer is D: A clie