2024\2025 A+ Grade
Which of the following findings should the nurse identify require follow-up by the provider? Select 6
findings that require immediate follow-up?
HR
Bowel sounds
Urinary output
BP
Orientation status
O2 SAT
Pain lvl
RR
Dressing appearance
- correct answer HR
BP
O2 SAT
Pain
RR
Dressing appearance
The nurse is reviewing the client's medical record. Which of the following findings should the nurse
identify require immediate follow-up? Select 4 findings that require immediate follow-up
O2 SAT
Nausea
Weakness
, BP
RR
Diaphoresis
ECG results
- correct answer O2 SAT
BP
RR
ECG results
A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of
the following behaviors should the charge nurse identify as an indication that the staff nurse might be
working while impaired?
- correct answer Frequent use of the restroom
A charge nurse is preparing to observe a newly licensed nurse to perform a routine abdominal
assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to
take?
- correct answer Place the client in a dorsal recumbent position for the examination
A nurse walks into the nurse's station and sees several staff members looking at the electronic medical
record for a celebrity client on another unit. Which of the following actions should the nurse take first?
- correct answer Remind the staff members that this a breach of confidentiality
A facility has been notified of a train derailment resulting in multiple clients experiencing life-
threatening injuries. The external disaster plan has been activated. Which of the following actions
should a charge nurse on the PACU take?
- correct answer Identify stable clients for transfer to a surgical unit
An assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the
clients who are incontinent. Which of the following responses should the charge nurse make?
- correct answer I delegate tasks to personnel based on their job descriptions