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A nurse is caring for a client who received a skin tear during a routine dressing change. After completing
an incident report, which of the following actions should the nurse take?
Submit the incident report to the nurse manager for review
A nurse is preparing to delegate assignments after receiving change of shift report. Which of the following
tasks should the nurse assign to an assistive personnel (AP)?
Provide postmortem care
A charge nurse in a long term care facility is reviewing message boards in various client rooms. Which
of the following information should the charge nurse request one of the nurses remove from a clients's
board?
"Hospice nurse visit at 1600"
A charge nurse is a member of the resource management team for a skilled care facility. Which of the
following actions should the charge nurse implement to ensure the facility is providing cost-effective
wound care for clients?
Develop a spreadsheet to prepare a budget for wound care supplies
A nurse is participating on a committee that is revising the facilty's policies and procedures for infection
control. Which of the following statements should the nurse recommend to include in the facility's
infection control manual?
Use a 1:10 bleach solution to clean blood spills
, A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following
client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
A nurse is caring for an adolescent client who requires a blood transfusion. The client's parents will not
consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take?
Inform the charge nurse and recommend that social services be contacted
A nurse in a long term care facility is caring for a client who had a stroke 1 week ago. the client is
experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and
memory loss. Which of the following referrals is the priority for the nurse to make?
Speech Therapy
A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of
the following manifestations should the nurse include?
Headaches
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of
the following events should the nurse document as a variance?
The client has a circular area of nonblanchable redness on her left heel
A nurse is assisting with discharge planning for a client. Which of the following actions should the plan to
take?
Include community resource phone numbers with the clients discharge instructions