Leadership & Management NCLEX Exam Questions & Answers with Complete Solution Graded A

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes - 4. Every 30 minutes The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed. The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity. 2. Remove jewellery and constricting clothing from the victim. 3. Place the extremity in a position so that it is below the level of the heart. 4. Move the victim to a safe area away from the snake and encourage the victim to rest. - 4. Move the victim to a safe area away from the snake and encourage the victim to rest. In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewellery and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible. The nurse is caring for 4 paediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head - 2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time. The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1. A client who has a tympanic temperature of 99.8º F 2. A client who has a regular radial pulse of 96 beats/min 3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% - 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is needed to maintain the client's oxygenation status. A tympanic temperature of 99.8º F is mildly elevated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96 beats/min is elevated as is the supine resting blood pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than respiratory status. The nurse has received the client assignment for the day. Which client should the nurse care for first? 1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination - 4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the primary health care provider 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. The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experiencing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim experiencing altered level of consciousness - 3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows. A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes 2. Get directions about care from the client's sister 3. Prepare for emergency intubation 4. Request that the sister provide a living will - 2. Get directions about care from the client's sister A medial POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances. The client's sister is designated as her POA. Though spouses are typically POA, option 1 is incorrect as he is not the designated POA. Option 3 would be appropriate only if there were no advance directives or family member present. Option 4 delays treatment. The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study? - 2. Do the characteristics of the sample population match those of the nurse's unit? When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate? 1. 3 year old with a temperature of 102.4 F (39.1 C) who had a seizure at home 30 minutes ago and is very irritable 2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale 3. 32 year old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best 4. 72 year old prescribe antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash - 2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale A fractured clavicle is not uncommon in children age <10 years and is usually treated conservatively. Additionally, the 8 year old has minimal pain and is therefore the most stable. The new nurse should be given the most stable patient. The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to unlicensed assistive personnel? Select all that apply. 1. Administer artificial tears if the client reports eye dryness 2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request 4. Reinforce to the client that fever is expected with thyrotoxicosis 5. Return a call to the client's family telling them the client's condition is unchanged - 2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request UAP are authorized to perform activities of daily living, hygiene, linen changes, and positioning. Therefore, Option 2 and 3 are within a UAP's scope of practice. Option 1 involves medication administration, which is under the scope of a RN. Option 4 involves client teaching and also falls in the scope of practice of a RN. Although placing a phone call can be delegated, providing family with updates about the client's condition may require teaching and psychosocial support; therefore, Option 5 is not an appropriate task for UAP. The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. "I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset." - 2. "I hope others will be helped through my involvement." Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and propose of the study. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation. Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% 2. Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3. Middle aged client with vaginal itching and white, curdlike discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face - 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (e.g., rescue position, head of bed elevation, intubation). The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? 1. Assess skin to determine severity of burns and wounds 2. Assign client to a cot with other similarly triaged clients 3. Assist the client to the designated showering area 4. Prepare supplies to establish intravenous access - 3. Assist the client to the designated showering area In the event of a disaster involving the release of hazardous substances, decontamination is vital to limit injury to the client and prevent exposure to other clients and staff. Disaster triage areas typically include a decontamination area. As long as the chemical remains on the skin, further injury may occur. The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain - 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion. The float nurse would not be familiar with the location of diabetic teaching materials, documentation procedure, or referral resources. The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply. 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 3. Evaluating partial thromboplastin time in a client receiving heparin 4. Measuring a client with chronic heart failure for compression stockings 5. Teaching a client with a new prescription for warfarin about bleeding precautions - 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 4. Measuring a client with chronic heart failure for compression stockings It is within the scope of practice of the LPN to administer most anticoagulant medications and measure/apply compression devices. Evaluating data and initial education is in the RN's scope of practice. The nurse receives the hand off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? 1. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria - 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances, and potential cardiac dysrhythmias. Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new onset atrial fibrillation - 2. A client with Cushing syndrome who needs intermittent urinary catheterization Routine procedures such as urinary catheterization fall well within the LPN scope of practice. The other clients are in crisis and unstable, requiring acute care by an RN. The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete and the client is awake - 2. Call the client's medical power of attorney to provide consent for the additional procedure Clients unconscious or under the influence of mind-altering drugs (e.g., opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent. It is in the client's best interest to have the hernia repaired now rather than go through the physical and financial strain of a secondary surgery. The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an appendectomy today and reports severe nausea and 8 out of 10 pain 2. Client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL (16.7 mmol/L) 3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) 4. Client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr - 3. Client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg (4.0 kPa) This client is experiencing systemic inflammatory response syndrome (SIRS), which can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. These clients require aggressive fluid resuscitation and treatment to address possible causes. A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? 1. Firmly indicate that the HCP cannot speak to the nurse in that manner 2. Immediately apologize and attempt to fix the situation 3. Say nothing and let the HCP vent frustrations 4. State that the conversation needs to take place in private and walk to a room - 4. State that the conversation needs to take place in private and walk to a room When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference. A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? 1. Client 3 days following a myocardial infarction who is on 6 L of oxygen and report nausea 2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO 3. Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min 4. Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG - 2. Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client who BP is controlled by oral medication, and has the knowledge and skill to assess vital signs. Unstable angina (angina at rest) is a medical emergency that requires specialist-level monitoring and intervention. A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold - 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. However, the client is not radioactive or infectious and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV rout 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L) 3. Client undergoing ultrafiltration for congestive heart failure 4. Client with a prescription for routine hemodialysis who has chronic renal failure - 4. Client with a prescription for routine hemodialysis who has chronic renal failure The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. With Option 1, there is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. The Option 1 client should be assigned to a more experience nurse. Multiple clients arrive at the emergency department. Which client should the triage nurse prioritize for the health care provider to see first? 1. Client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm 2. Client with dementia arriving with new onset restlessness and confusion 3. Client with epilepsy who had a seizure earlier but is now alert and oriented 4. Client with newly deformed forearm with normal circulation and sensation, pain rated 8/10 - 2. Client with dementia arriving with new onset restlessness and confusion Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline. The sudden onset of a new behavior may indicate delirium caused by an infection or another serious etiology and is therefore considered a priority. The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply? 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level - 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level Potassium-sparing diuretics, ACE inhibitors and angiotensin II receptor blockers (candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia. Aminoglycosides (tobramycin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. Personally go and auscultate the client's lungs - 4. Personally go and auscultate the client's lungs When a registered nurse (RN) receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be used to decide if an urgent need exists and a change in the nursing plan of care is needed. Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and photophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge 4. Client with sudden onset of the "worse headache of my life" - 4. Client with sudden onset of the "worse headache of my life" A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1. Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker - 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately The RN can safely delegate taks to the UAP that promote client safety during toileting and ambulating. Alterations in gait, balance, and range of motion places the client at a higher risk for falling. Evaluating the client for gait and balance deficits requires assessment and is a function of the registered nurse. The UAP may assist the client in ambulating with assistive devices, but evaluating and educating are not delegated. Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8 year old client who uses corticosteroid inhaler and has white patches on the tongue 2. 50 year old client who developed a smooth, red, pinpoint rash after taking sulfa 3. 60 year old client with pain and crusted blisters along the back 4. 70 year old client who has erythema with a small pustule at the hair follicle - 2. 50 year old client who developed a smooth, red, pinpoint rash after taking sulfa Petechiae can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptoms takes priority over a more localized dermatological presentation. Option 3 indicates shingles. However it is deemed a second priority as it is a localized issue. The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1 day post tubal myringotomy client with purulent tympanic drainage 2. A 4 day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae 3. A 10 day old client with a patent ductus arteriosus who has a continuous murmur 4. A 6 year old client with epiglottitis who is drooling and has a severe sore throat - 4. A 6 year old client with epiglottitis who is drooling and has a severe sore throat Epiglottitis refers to inflammation of the epiglottis that may result in life threatening airway obstruction. This client should be assessed first due to being unstable from an airway disorder. Option 2 could indicate endocarditis, however this is a circulation disorder and would therefore need to be seen second. The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3 year old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2. A 7 year old has had a high fever, cough, and sore throat for the past 2 days 3. A 12 year old with asthma controlled with a corticosteroid inhaler developed oral white patches 4. A 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain - 4. A 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16 year old needs to be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. An emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Five year old with a superficial leg laceration 2. Lethargic 3 month old with diarrhea for the past 12 hours 3. Seven year old with a elevated temperature of 101 F and hematuria 4. Seventeen year old with severe, acute abdominal pain - 2. Lethargic 3 month old with diarrhea for the past 12 hours Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic, indicating a change in LOC. Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift - 1. Administering hydromorphone without a prescription 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense and is reportable in all states (Option 4). Abandonment (eg leaving without proper replacement of personnel) is reportable in all states (Option 5). A client with end stage renal disease, oxygen dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the health care provider (HCP) stat 3. Check the apical pulse 4. Check the blood pressure - 3. Check the apical pulse The nurse should assess the client first and then call the HCP. A stat page is not needed when the client is DNR. Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply. 1. Assist the registered nurse with ambulating a client 1 day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery - 1. Assist the registered nurse with ambulating a client 1 day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery UAP may perform routine tasks for stable clients under the direction of the RN. Tasks related to the nursing process (eg assessment, planning, evaluation) require trained knowledge, critical thinking, and individualized application by the RN and cannot be delegated. A RN, LPN, and UAP are caring for a client who is 1 day postoperative gastric bypass surgery. Which pain management related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management - 1. Administering oral pain medication 4. Monitoring pain level using a numeric scale The RN is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain, performing initial client and caregiver teaching, and evaluating the effectiveness of the care plan (Option 2 and 5). The RN should delegate vital sign measurement to the UAP. Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources. The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? 1. Student who feels well but is concerned about possible exposure to viral meningitis at an off campus party 2 weeks ago 2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic stricken with severe vaginal pain 4. Student with itchy, cottage cheese like vaginal discharge who is sexually active and worried about having a sexually transmitted infection - 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic stricken with severe vaginal pain Sexual assault is a medical emergency requiring a thorough head to toe physical examination by a specially trained health care provider (eg sexual assault nurse examiner) to identify and treat injuries. The nurse is triaging client in the emergency department. Which client needs to be seen first? 1. 18 year old female with fever, suprapubic pain, and dysruia 2. 21 year old male with diffuse abdominal pain and a rigid abdomen 3. 64 year old male with a pulsatile mass in the periumbilical area and back pain 4. 75 year old with nausea, fever, and left lower quadrant pain - 3. 64 year old male with a pulsatile mass in the periumbilical area and back pain Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28 year old with infective endocarditis and heart rate of 105/min 2. 45 year old with acute pancreatitis and sinus tachycardia of 120/min 3. 65 year old with tachycardia of 110/min after liver biopsy 4. 74 year old on diltiazem drip with atrial fibrillation and heart rate of 115/min - 3. 65 year old with tachycardia of 110/min after liver biopsy The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65 year old client should be assessed first The HCP remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager 2. Tell the HCP to stop the comments 3. Walk away and say nothing 4. Write up an incident report - 2. Tell the HCP to stop the comments Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stope. IF that is not effective, additional action should be taken. A client with AIDS treated for intractable seizure is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? 1. Room 1 - client with Clostridium difficile 2. Room 2 - client with fever of unknown origin 3. Room 3 - client with bacterial pneumonia 4. Room 4 - client with upper gastrointestinal bleed - 4. Room 4 - client with upper gastrointestinal bleed The best option is room 4 as the client with the upper gastrointestinal bleed does not put the immunocompromised client with AIDS at increased risk for infection. A nurse working in the office of a HCP must respond to client telephone messages. The nurse should return which call first? 1. Client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone. 2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot 3. Client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting 4. Client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia - 2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot Musculoskeletal injuries and immobilization devices (cast) can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia is an early sign of neurovascular impairment. It would be important for the client to report to the HCP for immediate evaluation.